Provider Demographics
NPI:1679510895
Name:BAGWELL, MICHAEL (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1111
Mailing Address - Country:US
Mailing Address - Phone:409-898-6485
Mailing Address - Fax:
Practice Address - Street 1:950 N 14TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1111
Practice Address - Country:US
Practice Address - Phone:409-898-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-040392367500000X
TX536442367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3758OtherBCBS NON PAR NUMBER
FLG3758OtherBCBS NON PAR NUMBER