Provider Demographics
NPI:1871572578
Name:FEAGANS, MARY L (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:FEAGANS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5800
Mailing Address - Fax:601-261-3530
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5800
Practice Address - Fax:601-261-3530
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200038363AM0700X
MSPA00165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1591149Medicaid
MS05202536Medicaid
MS9464394OtherAETNA
MS3122240OtherUNITED HEALTHCARE
MS302I978316OtherMEDICARE PTAN
MS8740773OtherCIGNA
LA1591149Medicaid
MS8740773OtherCIGNA