Provider Demographics
NPI:1790872000
Name:HAGEN, BRYAN M (DNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:M
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 N HIGHWAY 97 STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7559
Mailing Address - Country:US
Mailing Address - Phone:541-313-8501
Mailing Address - Fax:541-241-2363
Practice Address - Street 1:2955 N HIGHWAY 97 STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7559
Practice Address - Country:US
Practice Address - Phone:541-313-8501
Practice Address - Fax:541-241-2363
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201042999RN163WP0809X
OR201250173NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500689745Medicaid