Healthcare Provider Details

I. General information

NPI: 1114978541
Provider Name (Legal Business Name): GINA MARIE BAGNERIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/16/2024
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 RUE ANGELIQUE
CARENCRO LA
70520-5656
US

IV. Provider business mailing address

17438 HARD HAT DR
COVINGTON LA
70435-5630
US

V. Phone/Fax

Practice location:
  • Phone: 337-886-4707
  • Fax:
Mailing address:
  • Phone: 985-249-5600
  • Fax: 985-249-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD18396
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number021394
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: