Provider Demographics
NPI:1891363677
Name:BAGWELL, MICHAEL BRENT (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRENT
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 S GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4510
Mailing Address - Country:US
Mailing Address - Phone:770-530-0082
Mailing Address - Fax:
Practice Address - Street 1:351 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2639
Practice Address - Country:US
Practice Address - Phone:541-881-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64152225100000X
IDPT-7198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist