Provider Demographics
NPI:1679752315
Name:HAGEN, SCOTT W (NP-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:HAGEN
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7014 N WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0155
Mailing Address - Country:US
Mailing Address - Phone:559-321-2858
Mailing Address - Fax:559-321-2780
Practice Address - Street 1:7014 N WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0155
Practice Address - Country:US
Practice Address - Phone:559-321-2858
Practice Address - Fax:559-321-2780
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB874ZMedicare PIN