=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457212730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAGWELL FAMILY MEDICINE P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2025
-----------------------------------------------------
Last Update Date | 11/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3487 EDGE RD
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73439-8881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-215-0494
-----------------------------------------------------
Fax | 469-215-0494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3487 EDGE RD
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73439-8881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-215-0494
-----------------------------------------------------
Fax | 469-215-0494
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FNP
-----------------------------------------------------
Name | MRS. AMANDA BAGWELL
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 469-215-0494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------