Provider Demographics
NPI:1154648921
Name:WAAGE, KAGEN ARTHUR
Entity Type:Individual
Prefix:
First Name:KAGEN
Middle Name:ARTHUR
Last Name:WAAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MAHNOMEN
Mailing Address - State:MN
Mailing Address - Zip Code:56557-4208
Mailing Address - Country:US
Mailing Address - Phone:218-935-2514
Mailing Address - Fax:218-935-2720
Practice Address - Street 1:410 4TH ST NW
Practice Address - Street 2:
Practice Address - City:MAHNOMEN
Practice Address - State:MN
Practice Address - Zip Code:56557-4208
Practice Address - Country:US
Practice Address - Phone:218-935-2514
Practice Address - Fax:218-935-2720
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10771363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN71062Medicaid
MN970004725Medicare PIN
MN970004726Medicare PIN
MN970004729Medicare PIN
MN71062Medicaid
970004727Medicare PIN