Provider Demographics
NPI:1780023143
Name:HAGAN, HEATHER ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:HAGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ELIZABETH
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:1108 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4317
Practice Address - Country:US
Practice Address - Phone:360-452-8216
Practice Address - Fax:360-452-5765
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60385021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1780023143Medicaid
WAP01338325OtherRR MEDICARE
WA1780023143Medicaid