Provider Demographics
NPI:1477242345
Name:HAGSTROM, MEREDITH LOGAN
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:LOGAN
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 COVINGTON CV
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:TX
Mailing Address - Zip Code:75407-3024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5406 WESLEY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6311
Practice Address - Country:US
Practice Address - Phone:903-355-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant