Provider Demographics
NPI:1205238789
Name:PERRY-BAGEAC, ELLEN (NP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:PERRY-BAGEAC
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 1:2617 SW GEORGIAN PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-1725
Mailing Address - Country:US
Mailing Address - Phone:503-267-9391
Mailing Address - Fax:
Practice Address - Street 1:3417 GASTON AVE STE 790
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-821-5266
Practice Address - Fax:214-821-0459
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty