Provider Demographics
NPI:1740516301
Name:DAGGETT, COURTNEY L (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:DAGGETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:L
Other - Last Name:THERIAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-858-8353
Mailing Address - Fax:207-474-9261
Practice Address - Street 1:46 FAIRVIEW AVE STE 111
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1481
Practice Address - Country:US
Practice Address - Phone:207-474-3320
Practice Address - Fax:207-474-5067
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1192363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1740516301Medicaid
0013887Medicare UPIN