Provider Demographics
NPI:1790790376
Name:BAGNIEWSKI, ABE CHARLES (DPM)
Entity Type:Individual
Prefix:DR
First Name:ABE
Middle Name:CHARLES
Last Name:BAGNIEWSKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 LILLY RD NE STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5086
Mailing Address - Country:US
Mailing Address - Phone:360-438-9092
Mailing Address - Fax:360-438-3906
Practice Address - Street 1:165 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5086
Practice Address - Country:US
Practice Address - Phone:360-438-9092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000775213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0204603OtherSTATE L&I
WA1001166Medicaid
WA8940526OtherCRIME VICTIMS
WAG8859310Medicare PIN
WA0204603OtherSTATE L&I