Provider Demographics
NPI:1073808739
Name:HAGEN, CHERYL ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:ANN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1230 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5066
Mailing Address - Country:US
Mailing Address - Phone:507-389-8502
Mailing Address - Fax:507-625-3928
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5066
Practice Address - Country:US
Practice Address - Phone:507-389-8502
Practice Address - Fax:507-625-3928
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10968363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970005584Medicare PIN