Provider Demographics
NPI:1043618572
Name:DAGENAIS & ASSOCIATES MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:DAGENAIS & ASSOCIATES MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:DAGENAIS
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:918-217-8696
Mailing Address - Street 1:539 LEAHY AVE
Mailing Address - Street 2:
Mailing Address - City:PAWHUSKA
Mailing Address - State:OK
Mailing Address - Zip Code:74056-5241
Mailing Address - Country:US
Mailing Address - Phone:918-217-8696
Mailing Address - Fax:918-217-8696
Practice Address - Street 1:137 EAST MAIN
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056
Practice Address - Country:US
Practice Address - Phone:918-217-8696
Practice Address - Fax:918-217-8696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1218363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty