Provider Demographics
NPI:1740489970
Name:HAGAN, JOHN (CRNP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HAGAN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8040
Mailing Address - Fax:443-462-3514
Practice Address - Street 1:827 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4606
Practice Address - Country:US
Practice Address - Phone:410-328-8141
Practice Address - Fax:410-328-0177
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR079848363LC0200X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS062-0376OtherBLUE CROSS REGIONAL
MD419031900Medicaid
MD960548-01 & 02OtherBLUE CROSS/BLUE SHIELD
MDS062-0376OtherBLUE CROSS REGIONAL
MD419031900Medicaid