Provider Demographics
NPI:1710947064
Name:BAGIN, JEAN (NP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:BAGIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N14W23900 STONE RIDGE DR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1135
Mailing Address - Country:US
Mailing Address - Phone:262-574-8000
Mailing Address - Fax:
Practice Address - Street 1:N14W23900 STONE RIDGE DR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1135
Practice Address - Country:US
Practice Address - Phone:262-574-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43937600Medicaid
WIP41340Medicare UPIN
WI43937600Medicaid