Basic Information
| Provider Information | |||||||||
| NPI: | 1639412125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DARAGON | ||||||||
| FirstName: | ELLISANDRE | ||||||||
| MiddleName: | MORGAN LARRABEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7500 RIALTO BLVD STE 1-140 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787358534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127303056 | ||||||||
| FaxNumber: | 8887301925 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 9662057-1205 | UT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 68799-20 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2017034039 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M13548 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.