Provider Demographics
NPI:1760559546
Name:HAGADORN, MICHAEL L (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:HAGADORN
Suffix:
Gender:M
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:PO BOX 2868
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0259
Mailing Address - Country:US
Mailing Address - Phone:518-562-7900
Mailing Address - Fax:518-562-7933
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-561-2000
Practice Address - Fax:518-561-0881
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008392-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY114406OtherVALUE OPTIONS
NY90031OtherMVP
NYSE08R10010OtherEMPIRE
NY000490094001OtherBSNENY
NY02292102Medicaid
P60054Medicare UPIN
DD1321Medicare ID - Type Unspecified