Provider Demographics
NPI:1114382637
Name:BAGGETT, BLAYNE DAVID
Entity Type:Individual
Prefix:
First Name:BLAYNE
Middle Name:DAVID
Last Name:BAGGETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N LEROY ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2729
Mailing Address - Country:US
Mailing Address - Phone:810-629-9200
Mailing Address - Fax:810-629-9653
Practice Address - Street 1:305 N LEROY ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2729
Practice Address - Country:US
Practice Address - Phone:810-629-9200
Practice Address - Fax:810-629-9653
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant