Basic Information
| Provider Information | |||||||||
| NPI: | 1700387214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGWELL | ||||||||
| FirstName: | BREANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11279 PERRY HWY STE 450 | ||||||||
| Address2: | SUITE 100 A | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909303 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 LOCUST ST | ||||||||
| Address2: | SUITE 100 A | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152195114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122328111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2018 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | SP018582 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.