Provider Demographics
NPI:1780718684
Name:BAILLARGEON, MARY T (MPAS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BAILLARGEON
Suffix:
Gender:F
Credentials:MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106-2504
Mailing Address - Country:US
Mailing Address - Phone:603-622-6484
Mailing Address - Fax:603-647-8593
Practice Address - Street 1:200 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:HOOKSETT
Practice Address - State:NH
Practice Address - Zip Code:03106-2504
Practice Address - Country:US
Practice Address - Phone:603-622-6484
Practice Address - Fax:603-647-8593
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0625363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30335008Medicaid
NHQ77714Medicare UPIN
NH000002205Medicare PIN
NH000002204Medicare PIN