Provider Demographics
NPI:1063457265
Name:HAGAN, MICHELLE N (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:N
Last Name:HAGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 HAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5022
Mailing Address - Country:US
Mailing Address - Phone:440-413-6272
Mailing Address - Fax:
Practice Address - Street 1:33290 BAINBRIDGE RD
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2802
Practice Address - Country:US
Practice Address - Phone:440-600-7675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002361363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ56966Medicare UPIN
OHHAPA25972Medicare ID - Type Unspecified