Provider Demographics
NPI:1467595348
Name:BRAGUNIER, JACQUELINE CLAIRE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CLAIRE
Last Name:BRAGUNIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4823 43RD PL NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4501
Mailing Address - Country:US
Mailing Address - Phone:313-729-5797
Mailing Address - Fax:
Practice Address - Street 1:3500 OLD WASHINGTON RD
Practice Address - Street 2:101
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602
Practice Address - Country:US
Practice Address - Phone:301-645-1133
Practice Address - Fax:301-645-2369
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003956363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL385001555OtherSTATE LICENSE