Provider Demographics
NPI:1518950559
Name:HAGAN, JON C (PT)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:HAGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3026
Mailing Address - Country:US
Mailing Address - Phone:617-724-8157
Mailing Address - Fax:617-724-9332
Practice Address - Street 1:73 HIGH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-3026
Practice Address - Country:US
Practice Address - Phone:617-724-8157
Practice Address - Fax:617-724-9332
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHA Y68290Medicare ID - Type Unspecified