Provider Demographics
NPI:1689666364
Name:DAGENAIS, MARY J (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:DAGENAIS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:9415 E HARRY ST STE 602
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-5082
Mailing Address - Country:US
Mailing Address - Phone:316-681-2420
Mailing Address - Fax:316-681-3561
Practice Address - Street 1:9415 E HARRY ST STE 602
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-5082
Practice Address - Country:US
Practice Address - Phone:316-681-2420
Practice Address - Fax:316-681-3561
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1218363A00000X
KS15-00874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant