Provider Demographics
NPI:1699855767
Name:BAGGETT, CHERYL ALICIA (PA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ALICIA
Last Name:BAGGETT
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 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:SUITE 420
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2408
Mailing Address - Country:US
Mailing Address - Phone:618-899-4000
Mailing Address - Fax:618-899-4790
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:SUITE 420
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2408
Practice Address - Country:US
Practice Address - Phone:618-899-4000
Practice Address - Fax:618-899-4790
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00365758OtherRR NUMBER
IL85002319OtherLICENSE
ILCE9335OtherRR GROUP
ILP00365758OtherRR NUMBER