Basic Information
| Provider Information | |||||||||
| NPI: | 1851480354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN STE 220 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615732481 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN STE 220 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615732481 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 586524 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | CR35297 | 01 | TX | WORKERS COMP | OTHER | 88797C | 01 | TX | BLUE CROSS | OTHER | 742710179A017 | 01 | TX | CHAMPUS | OTHER |