Provider Demographics
NPI:1306979786
Name:FAGAN, BRYAN IGNATIUS (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:IGNATIUS
Last Name:FAGAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LEWIS CT
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-2244
Mailing Address - Country:US
Mailing Address - Phone:410-287-6977
Mailing Address - Fax:
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002882363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD489PR162Medicare PIN
MDR162Medicare PIN