Provider Demographics
NPI:1265551469
Name:DAGGETT, MARY LORING (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LORING
Last Name:DAGGETT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:DAGGETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:2305 CALLE PINTURA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5273
Mailing Address - Country:US
Mailing Address - Phone:505-471-2569
Mailing Address - Fax:
Practice Address - Street 1:BIKINI ATOLL ROAD MS D421
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87545
Practice Address - Country:US
Practice Address - Phone:505-665-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-PA30363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK3602Medicaid
NMK3602Medicaid