Provider Demographics
NPI:1760454268
Name:HAGEMAN, JOANN (PA)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:HAGEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 S 101ST EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5716
Mailing Address - Country:US
Mailing Address - Phone:918-294-6911
Mailing Address - Fax:918-294-4759
Practice Address - Street 1:8801 S 101ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5716
Practice Address - Country:US
Practice Address - Phone:918-294-6911
Practice Address - Fax:918-294-4759
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1151363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200093200AMedicaid
NE470748011-12Medicaid
278197SUMedicare ID - Type Unspecified
OK200093200AMedicaid
OK243629906Medicare PIN