1437550936 NPI number — TRACY TEICHEN BAGGETT PHYSICIAN ASSISTANT

Table of content: TRACY TEICHEN BAGGETT PHYSICIAN ASSISTANT (NPI 1437550936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437550936 NPI number — TRACY TEICHEN BAGGETT PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGGETT
Provider First Name:
TRACY
Provider Middle Name:
TEICHEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROOK
Provider Other First Name:
TRACY
Provider Other Middle Name:
TEICHEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437550936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100296
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32610-0296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-294-5252
Provider Business Mailing Address Fax Number:
352-294-8068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 SW ARCHER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32610-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-265-8250
Provider Business Practice Location Address Fax Number:
352-294-8068
Provider Enumeration Date:
09/16/2014

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: 363A00000X , with the licence number:  PA9108200 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 015585300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".