Healthcare Provider Details

I. General information

NPI: 1932566874
Provider Name (Legal Business Name): JACQUELINE BAGGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 16TH AVE N
NAMPA ID
83687-4058
US

IV. Provider business mailing address

1914 N 14TH ST
BOISE ID
83702-1101
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-7654
  • Fax: 208-466-5359
Mailing address:
  • Phone: 208-794-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: