Provider Demographics
NPI:1164904264
Name:BAGWELL, EVAN JAMES
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:BAGWELL
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 1:153 MASSEY RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-9056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 RIVER RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-1538
Practice Address - Country:US
Practice Address - Phone:864-934-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program