Provider Demographics
NPI:1114978541
Name:BAGNERIS, GINA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:BAGNERIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17438 HARD HAT DRIVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435
Mailing Address - Country:US
Mailing Address - Phone:985-249-5600
Mailing Address - Fax:985-249-5618
Practice Address - Street 1:108 RUE ANGELIQUE
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-5656
Practice Address - Country:US
Practice Address - Phone:337-886-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18396207P00000X
LA021394207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1959561Medicaid
LA1959561Medicaid
LAF48409Medicare UPIN