Provider Demographics
NPI:1043473267
Name:BAGSHAW, MARY TERESA (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:BAGSHAW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 0861
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0001
Mailing Address - Country:US
Mailing Address - Phone:866-898-7136
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:2635 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8209
Practice Address - Country:US
Practice Address - Phone:970-244-1977
Practice Address - Fax:970-244-2898
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73645363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67126855Medicaid