Provider Demographics
NPI:1255384228
Name:HAGAR, MARYANNE (APRN)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:HAGAR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SIX CORPORATE DRIVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484
Mailing Address - Country:US
Mailing Address - Phone:203-925-9600
Mailing Address - Fax:203-926-0594
Practice Address - Street 1:SIX CORPORATE DRIVE
Practice Address - Street 2:SUITE 420
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-925-9600
Practice Address - Fax:203-926-0594
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002546363L00000X, 363LP0808X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP63325Medicare UPIN