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General NPI Number Information
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NPI Number | 1083653745
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Entity Type | Individual
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Provider Name | JACK LLORRAC BAGLEY PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/06/2006
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Last Update Date | 12/22/2025
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Provider Practice Location Address
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Address Line | 2729 HORSE PEN CREEK RD STE 105
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City | GREENSBORO
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State | NC
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Zip | 27410-8396
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Country | US
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Telephone | 336-907-7773
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Fax | 336-907-7902
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Provider Business Mailing Address
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Address Line | PO BOX 96860
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City | CHARLOTTE
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State | NC
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Zip | 28296-6860
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Country | US
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Telephone | 704-542-6111
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Fax | 704-542-1239
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2006004610
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 103055
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License Number State | NC
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