Provider Demographics
NPI:1508807785
Name:HAGERMAN, JAMES ROGER (PA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROGER
Last Name:HAGERMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PLEASANT VALLEY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-9774
Mailing Address - Country:US
Mailing Address - Phone:270-417-7500
Mailing Address - Fax:270-417-7509
Practice Address - Street 1:1301 PLEASANT VALLEY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7500
Practice Address - Fax:270-417-7509
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA453363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000491613OtherANTHEM
KY11621267OtherCAQH
KY363AM0700XOtherTAXONOMY
KY11621267OtherCAQH
KYK004910Medicare PIN
KY363AM0700XOtherTAXONOMY