Basic Information
Provider Information
NPI: 1003001561
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HAGMAN
FirstName: THERESA
MiddleName: ANN
NamePrefix: MRS.
NameSuffix:  
Credential: PTA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 2759
Address2:  
City: APPLETON
State: WI
PostalCode: 549122759
CountryCode: US
TelephoneNumber: 9208305900
FaxNumber: 9208305910
Practice Location
Address1: 1818 N MEADE ST
Address2:  
City: APPLETON
State: WI
PostalCode: 549113454
CountryCode: US
TelephoneNumber: 9207314101
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/07/2007
LastUpdateDate: 09/07/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225200000X  N Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant 
225200000X86-019WIY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant 

No ID Information.


Home