Provider Demographics
NPI:1356670350
Name:HAZEL, GINA OETGEN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:OETGEN
Last Name:HAZEL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 WATERS AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6278
Mailing Address - Country:US
Mailing Address - Phone:912-350-7412
Mailing Address - Fax:912-350-7297
Practice Address - Street 1:4750 WATERS AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-7412
Practice Address - Fax:912-350-7297
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN152773363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP01110452OtherRAILROAD MEDICARE
GA615817424DMedicaid
GA761061OtherWELLCARE
01721151OtherAMERIGROUP
GA615817424CMedicaid
SCNP2156Medicaid
GAP01278462OtherRAILROAD MEDICARE
GA202I508865Medicare PIN
01721151OtherAMERIGROUP