Provider Demographics
NPI:1639703820
Name:BAGWELL, BENSON ELLIOTT (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:BENSON
Middle Name:ELLIOTT
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-2057
Mailing Address - Country:US
Mailing Address - Phone:202-631-1232
Mailing Address - Fax:
Practice Address - Street 1:111 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2057
Practice Address - Country:US
Practice Address - Phone:202-631-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61040729363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily