Basic Information
| Provider Information | |||||||||
| NPI: | 1841719390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA0C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017595443 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2017 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | N | Other Service Providers | Military Health Care Provider | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 08402771 | 05 | MS | MEDICAID | Q061378 | 05 | TN | MEDICAID |