Provider Demographics
NPI:1285086454
Name:BAGNELL, PAUL MARTIN (COTA/L)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:MARTIN
Last Name:BAGNELL
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 CIRCLE BROOK DR APT L
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8214
Mailing Address - Country:US
Mailing Address - Phone:703-853-4584
Mailing Address - Fax:
Practice Address - Street 1:4920 WOODMAR DR SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1651
Practice Address - Country:US
Practice Address - Phone:540-400-0897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131-001616224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant