Provider Demographics
NPI:1669680393
Name:HAGAN, CONNIE (CRNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 W MERCER STREET EXT
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16038-1514
Mailing Address - Country:US
Mailing Address - Phone:724-735-4415
Mailing Address - Fax:
Practice Address - Street 1:565 KELLY BLVD
Practice Address - Street 2:
Practice Address - City:SLIPPERY ROCK
Practice Address - State:PA
Practice Address - Zip Code:16057-1155
Practice Address - Country:US
Practice Address - Phone:724-794-4023
Practice Address - Fax:724-794-3675
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN199361L363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAHA925951OtherHIGHMARK
PA1991407OtherHIGHMARK
PAHA925951OtherHIGHMARK
PA021968L5TMedicare PIN
PAS68258Medicare UPIN
PA021968PAZMedicare PIN