Provider Demographics
NPI:1558611673
Name:HAGOS, ABRAHAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ABRAHAM
Middle Name:
Last Name:HAGOS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14375 NASON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14375 NASON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4729
Practice Address - Country:US
Practice Address - Phone:951-486-4546
Practice Address - Fax:951-486-4295
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18390363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical