Provider Demographics
NPI:1649739988
Name:HAGAN, ELIZABETH ANNE
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:
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 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:253-459-8231
Mailing Address - Fax:
Practice Address - Street 1:1920 BLACK LAKE BLVD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5651
Practice Address - Country:US
Practice Address - Phone:360-534-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV390200000X
MO2020031769208000000X
WAMD61296052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program