Provider Demographics
NPI:1235524653
Name:HAGAN, KENTON LEE
Entity Type:Individual
Prefix:
First Name:KENTON
Middle Name:LEE
Last Name:HAGAN
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 1:3900 N PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6398
Mailing Address - Country:US
Mailing Address - Phone:479-966-4187
Mailing Address - Fax:479-966-4197
Practice Address - Street 1:3900 N PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6398
Practice Address - Country:US
Practice Address - Phone:479-966-4187
Practice Address - Fax:479-966-4197
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-12883207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty