Provider Demographics
NPI:1770370314
Name:BAGULEY, ANDREW (PA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BAGULEY
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 3687
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-2529
Mailing Address - Country:US
Mailing Address - Phone:208-819-2183
Mailing Address - Fax:208-209-6063
Practice Address - Street 1:2426 N MERRITT CREEK LOOP STE A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4961
Practice Address - Country:US
Practice Address - Phone:208-819-2183
Practice Address - Fax:208-209-6063
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-153622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant