1235472176 NPI number — DR. COURTNEY WEATHERSBY BAGAYOKO M.D.

Table of content: DR. COURTNEY WEATHERSBY BAGAYOKO M.D. (NPI 1235472176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235472176 NPI number — DR. COURTNEY WEATHERSBY BAGAYOKO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGAYOKO
Provider First Name:
COURTNEY
Provider Middle Name:
WEATHERSBY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEATHERSBY
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235472176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 E 82ND AVE STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99518-3159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-865-8455
Provider Business Mailing Address Fax Number:
913-246-4901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 E 82ND AVE STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99518-3159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-865-8455
Provider Business Practice Location Address Fax Number:
913-246-4901
Provider Enumeration Date:
03/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  124372 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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