Provider Demographics
NPI:1083653745
Name:BAGLEY, JACK LLORRAC (PA-C)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:LLORRAC
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 96860
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28296-6860
Mailing Address - Country:US
Mailing Address - Phone:704-542-6111
Mailing Address - Fax:704-542-1239
Practice Address - Street 1:2729 HORSE PEN CREEK RD STE 105
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8396
Practice Address - Country:US
Practice Address - Phone:336-907-7773
Practice Address - Fax:336-907-7902
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006004610363A00000X
NC103055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP20171Medicare UPIN