Provider Demographics
NPI:1144280470
Name:HAGEDORN, CHARLES M (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 PATRICIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:FALLS CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68355
Mailing Address - Country:US
Mailing Address - Phone:402-245-2980
Mailing Address - Fax:
Practice Address - Street 1:2307 BARADA ST
Practice Address - Street 2:CMC
Practice Address - City:FALLS CITY
Practice Address - State:NE
Practice Address - Zip Code:68355
Practice Address - Country:US
Practice Address - Phone:402-245-2428
Practice Address - Fax:402-245-6547
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100561367500000X
KS55374367500000X
OKR00081612367500000X
SDR022529367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered