Provider Demographics
NPI:1003592254
Name:HAZELGREN, DALLIN
Entity type:Individual
Prefix:
First Name:DALLIN
Middle Name:
Last Name:HAZELGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21169 E MISTY LN
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5062
Mailing Address - Country:US
Mailing Address - Phone:480-616-9814
Mailing Address - Fax:
Practice Address - Street 1:1900 N HIGLEY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1604
Practice Address - Country:US
Practice Address - Phone:480-543-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ149383367500000X
AZ229177367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered