Basic Information
| Provider Information | |||||||||
| NPI: | 1740516301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAGGETT | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THERIAULT | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 468 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049760468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078588353 | ||||||||
| FaxNumber: | 2074749261 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 FAIRVIEW AVE STE 111 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049761481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074743320 | ||||||||
| FaxNumber: | 2074745067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2009 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1192 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA1192 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1740516301 | 05 | ME | MEDICAID |