Provider Demographics
NPI:1700191426
Name:DAGEN, DEANDRA L (NP)
Entity Type:Individual
Prefix:
First Name:DEANDRA
Middle Name:L
Last Name:DAGEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 W FRYE RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6255
Mailing Address - Country:US
Mailing Address - Phone:480-895-9555
Mailing Address - Fax:480-895-9494
Practice Address - Street 1:1950 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6255
Practice Address - Country:US
Practice Address - Phone:480-895-9555
Practice Address - Fax:480-895-9494
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN128051363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ236276Medicaid