Provider Demographics
NPI:1720489818
Name:TYLER K. HAGAN, DPM, PLLC
Entity Type:Organization
Organization Name:TYLER K. HAGAN, DPM, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:252-633-3400
Mailing Address - Street 1:612A MCCARTHY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5231
Mailing Address - Country:US
Mailing Address - Phone:252-633-3400
Mailing Address - Fax:252-633-9338
Practice Address - Street 1:612A MCCARTHY BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5231
Practice Address - Country:US
Practice Address - Phone:252-633-3400
Practice Address - Fax:252-633-9338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC617213E00000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1588955231OtherINDIVIDUAL NPI
NC1588955231OtherINDIVIDUAL NPI