Provider Demographics
NPI:1659056356
Name:LAVIGNE-HAGEN, ANDREA RUTH (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:RUTH
Last Name:LAVIGNE-HAGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:330-493-6443
Mailing Address - Fax:330-493-8677
Practice Address - Street 1:13640 STEELECROFT PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7565
Practice Address - Country:US
Practice Address - Phone:704-512-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-13344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program