Provider Demographics
NPI:1003170747
Name:HAGEN, PATRICK DALE
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DALE
Last Name:HAGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4156 VANCOUVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-6143
Mailing Address - Country:US
Mailing Address - Phone:702-458-0225
Mailing Address - Fax:
Practice Address - Street 1:2770 S MARYLAND PKWY STE 310
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-1566
Practice Address - Country:US
Practice Address - Phone:702-240-3800
Practice Address - Fax:702-240-3001
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant