Provider Demographics
NPI:1093949364
Name:HAGAN, JANICE M (PA-C)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
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 1:5000 COX RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-822-4355
Mailing Address - Fax:
Practice Address - Street 1:2205 N PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-3161
Practice Address - Country:US
Practice Address - Phone:804-270-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001373363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV4666A - C03895Medicare PIN