Provider Demographics
NPI:1043381783
Name:HAGERMAN, WAYNE T (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:T
Last Name:HAGERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 KATLIAN ST
Mailing Address - Street 2:STE. C
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-7314
Mailing Address - Country:US
Mailing Address - Phone:907-747-6644
Mailing Address - Fax:907-747-4990
Practice Address - Street 1:700 KATLIAN ST
Practice Address - Street 2:STE. C
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-7314
Practice Address - Country:US
Practice Address - Phone:907-747-6644
Practice Address - Fax:907-747-4990
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKA55152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578881561OtherTYPE II NPI
AK0744520001Medicare NSC