Provider Demographics
NPI:1598457582
Name:HAGER, SHANE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:HAGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:PEMBINA
Mailing Address - State:ND
Mailing Address - Zip Code:58271-0059
Mailing Address - Country:US
Mailing Address - Phone:701-520-5477
Mailing Address - Fax:
Practice Address - Street 1:2732 E MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3164
Practice Address - Country:US
Practice Address - Phone:253-770-2732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61449532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist