Provider Demographics
NPI:1255304564
Name:HAGOOD, NICHOLAS R (PAC)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:R
Last Name:HAGOOD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1507 W MAIN ST
Mailing Address - Street 2:BLDG 1
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-1024
Mailing Address - Country:US
Mailing Address - Phone:254-265-7100
Mailing Address - Fax:254-875-0449
Practice Address - Street 1:1305 PALUXY RD STE A
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5641
Practice Address - Country:US
Practice Address - Phone:817-573-6673
Practice Address - Fax:817-573-9783
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARPA-693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA03300OtherSTATE LICENSE NUMBER
TXPA03300OtherSTATE LICENSE NUMBER