Provider Demographics
NPI:1689666364
Name:DAGENAIS, MARY J (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:DAGENAIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PAWHUSKA
Mailing Address - State:OK
Mailing Address - Zip Code:74056-5213
Mailing Address - Country:US
Mailing Address - Phone:918-217-8696
Mailing Address - Fax:918-217-8696
Practice Address - Street 1:539 LEAHY AVE
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-5241
Practice Address - Country:US
Practice Address - Phone:918-217-8696
Practice Address - Fax:918-217-8696
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant