Provider Demographics
NPI:1033395561
Name:HAGEMAN, MARTHA S (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:S
Last Name:HAGEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 PETERSEN PKWY
Mailing Address - Street 2:STE 4
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127
Mailing Address - Country:US
Mailing Address - Phone:307-883-5852
Mailing Address - Fax:307-883-4436
Practice Address - Street 1:122 PETERSEN PKWY
Practice Address - Street 2:STE 4
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-5852
Practice Address - Fax:307-883-4436
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5751A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine