Provider Demographics
NPI:1609014141
Name:BAGALSO, MARY GRACE Q (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY GRACE
Middle Name:Q
Last Name:BAGALSO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BAGALSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1946 YOUNG ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-2169
Mailing Address - Country:US
Mailing Address - Phone:808-973-7330
Mailing Address - Fax:808-973-7325
Practice Address - Street 1:888 S KING ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-3097
Practice Address - Country:US
Practice Address - Phone:808-522-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-62977367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered