Provider Demographics
NPI:1851480354
Name:HAGAN, JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HAGAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E MOCKINGBIRD LN STE 220
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2194
Mailing Address - Country:US
Mailing Address - Phone:361-573-2481
Mailing Address - Fax:361-576-2434
Practice Address - Street 1:1501 E MOCKINGBIRD LN STE 220
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2194
Practice Address - Country:US
Practice Address - Phone:361-573-2481
Practice Address - Fax:361-576-2434
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX586524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCR35297OtherWORKERS COMP
TX88797COtherBLUE CROSS
TX742710179A017OtherCHAMPUS
TX88797CMedicare ID - Type Unspecified