Provider Demographics
NPI:1639652605
Name:HAGEN, RYAN TIMOTHY (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TIMOTHY
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 ALBEMARLE SQ
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-7405
Mailing Address - Country:US
Mailing Address - Phone:434-817-7848
Mailing Address - Fax:
Practice Address - Street 1:111 MONTICELLO AVE STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5698
Practice Address - Country:US
Practice Address - Phone:434-817-4276
Practice Address - Fax:434-465-6836
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist