Provider Demographics
NPI:1619929064
Name:HAGBERG, CARRIE (NCP)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:
Last Name:HAGBERG
Suffix:
Gender:F
Credentials:NCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 22ND AVE.
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2497
Mailing Address - Country:US
Mailing Address - Phone:605-697-9500
Mailing Address - Fax:605-697-6939
Practice Address - Street 1:400 22ND AVE.
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2497
Practice Address - Country:US
Practice Address - Phone:605-697-9500
Practice Address - Fax:605-697-6939
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6820352Medicaid
SD6820352Medicaid
SDR02485Medicare UPIN