Provider Demographics
NPI:1972677474
Name:HAGA, BENNY RAY (NP)
Entity Type:Individual
Prefix:MR
First Name:BENNY
Middle Name:RAY
Last Name:HAGA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 WEST RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382
Mailing Address - Country:US
Mailing Address - Phone:276-223-1983
Mailing Address - Fax:276-223-1316
Practice Address - Street 1:1995 WEST RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382
Practice Address - Country:US
Practice Address - Phone:276-223-1983
Practice Address - Fax:276-223-1316
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001056493363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0102OtherJOHN DEERE HEALTH
500019629OtherRAILROAD MEDICARE
P18589Medicare UPIN
500019629OtherRAILROAD MEDICARE