Provider Demographics
NPI:1609104496
Name:HAGEN, NICHOLAS D (DPT, SCS, CSCS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:D
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DPT, SCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SW INDUSTRIAL WAY
Mailing Address - Street 2:STE 3
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1093
Mailing Address - Country:US
Mailing Address - Phone:541-585-2529
Mailing Address - Fax:541-585-2536
Practice Address - Street 1:1160 SW SIMPSON AVE
Practice Address - Street 2:STE 200
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702
Practice Address - Country:US
Practice Address - Phone:541-322-9045
Practice Address - Fax:541-322-9044
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR68562251S0007X, 2251S0007X
CA36265174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500695874Medicaid
OR500695874Medicaid