Provider Demographics
NPI:1164736419
Name:BAGOS, LYNSEY MARIE
Entity Type:Individual
Prefix:MRS
First Name:LYNSEY
Middle Name:MARIE
Last Name:BAGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42180 TODDMARK LN APT 12
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5491
Mailing Address - Country:US
Mailing Address - Phone:248-860-3501
Mailing Address - Fax:
Practice Address - Street 1:1101 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1863
Practice Address - Country:US
Practice Address - Phone:248-652-5354
Practice Address - Fax:248-652-5861
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250789367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12164771OtherCAQH