=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821852344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN BAGUR CCP, LP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2024
-----------------------------------------------------
Last Update Date | 02/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 ALLIED DR
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-814-3777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5808 SWEETBRIAR DR
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75082-4988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 242T00000X
-----------------------------------------------------
Taxonomy Name | Perfusionist
-----------------------------------------------------
License Number | FPF00000424
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------