Provider Demographics
NPI:1184731671
Name:HAGENE, SANDY R (FNP)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:R
Last Name:HAGENE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 OZARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-1664
Mailing Address - Country:US
Mailing Address - Phone:573-885-6600
Mailing Address - Fax:
Practice Address - Street 1:102 OZARK DR
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453
Practice Address - Country:US
Practice Address - Phone:573-885-6600
Practice Address - Fax:573-885-6610
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112906363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424651305Medicaid
S85512Medicare UPIN
MO000080449Medicare ID - Type Unspecified