Provider Demographics
NPI:1033520622
Name:HAGBERG, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:HAGBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15856 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-1827
Mailing Address - Country:US
Mailing Address - Phone:715-634-3000
Mailing Address - Fax:715-634-7501
Practice Address - Street 1:15856 E 5TH ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-1827
Practice Address - Country:US
Practice Address - Phone:715-634-3000
Practice Address - Fax:715-634-7501
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39-1519694172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-1519694OtherSPECIALIZED TRANSPORTATION