Healthcare Provider Details

I. General information

NPI: 1518688563
Provider Name (Legal Business Name): CALVIN DAGGETT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 W JEFFERSON BLVD
FORT WAYNE IN
46804-4133
US

IV. Provider business mailing address

PO BOX 2526
FORT WAYNE IN
46801-2526
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-8686
  • Fax:
Mailing address:
  • Phone: 260-436-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003749A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: