Provider Demographics
NPI:1407519119
Name:HAGAN, SHAD M
Entity Type:Individual
Prefix:
First Name:SHAD
Middle Name:M
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 1:46 WINDSOR CIR
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-6708
Mailing Address - Country:US
Mailing Address - Phone:405-564-2195
Mailing Address - Fax:
Practice Address - Street 1:1820 SOUTH VAN BUREN
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703
Practice Address - Country:US
Practice Address - Phone:405-762-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator