Provider Demographics
NPI:1184663973
Name:HAGEN, BRADLEY CHRISTOPHER (ARNP, FNP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:CHRISTOPHER
Last Name:HAGEN
Suffix:
Gender:M
Credentials:ARNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 BIDDLE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:418 W. MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-689-8900
Practice Address - Fax:509-689-9031
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR091006932N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30003371OtherSTATE LICENSE
WA0293305OtherL&I
WA1184663973Medicaid
WA1184663973Medicaid