Basic Information
| Provider Information | |||||||||
| NPI: | 1932853041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGNER | ||||||||
| FirstName: | MEGHAN | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | HAVERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190833424 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2022 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | SP024886 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | SP024886 | 01 | PA | CRNP LICENSE | OTHER | NPPA048633 | 01 | PA | PRESCRIPTIVE AUTHORITY | OTHER |