Basic Information
| Provider Information | |||||||||
| NPI: | 1871572578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEAGANS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012685800 | ||||||||
| FaxNumber: | 6012613530 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012685800 | ||||||||
| FaxNumber: | 6012613530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA200038 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA00165 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1591149 | 05 | LA | MEDICAID | 05202536 | 05 | MS | MEDICAID | 9464394 | 01 | MS | AETNA | OTHER | 3122240 | 01 | MS | UNITED HEALTHCARE | OTHER | 302I978316 | 01 | MS | MEDICARE PTAN | OTHER | 8740773 | 01 | MS | CIGNA | OTHER |