Provider Demographics
NPI:1659347896
Name:HAGAN, KEVIN M (CRNP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:HAGAN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 OLD YORK RD
Mailing Address - Street 2:5 TOLL
Mailing Address - City:ABINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19001-3720
Mailing Address - Country:US
Mailing Address - Phone:215-481-4200
Mailing Address - Fax:215-881-9587
Practice Address - Street 1:1200 OLD YORK RD
Practice Address - Street 2:5 TOLL
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3720
Practice Address - Country:US
Practice Address - Phone:215-481-4200
Practice Address - Fax:215-881-9587
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008480363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PW232359401OtherMAIN LINE HEALTHCARE
Q44239Medicare UPIN
PA091171HK1Medicare ID - Type Unspecified