Healthcare Provider Details

I. General information

NPI: 1215421094
Provider Name (Legal Business Name): ANNA DAGG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

IV. Provider business mailing address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-2511
  • Fax: 620-860-0619
Mailing address:
  • Phone: 620-792-2511
  • Fax: 620-860-0619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94-09610
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: