Provider Demographics
NPI:1558324715
Name:HAGAN, TRACY R (AOCNP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:R
Last Name:HAGAN
Suffix:
Gender:F
Credentials:AOCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1644
Practice Address - Country:US
Practice Address - Phone:270-825-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001230B363LA2100X
KY3005183363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00082583OtherRR MEDICARE
IN200445130Medicaid
KY78007838Medicaid
KYP01079960OtherRR MEDICARE
KYK038700Medicare PIN
INP77830Medicare UPIN
KY78007838Medicaid
KY00549003Medicare PIN