Provider Demographics
NPI:1770552051
Name:HAGEDORN, CATHERINE A (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:A
Last Name:HAGEDORN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W 53RD ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-2459
Mailing Address - Country:US
Mailing Address - Phone:563-421-3800
Mailing Address - Fax:563-421-3810
Practice Address - Street 1:1520 W 53RD ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-2459
Practice Address - Country:US
Practice Address - Phone:563-421-3800
Practice Address - Fax:563-421-3810
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001550207P00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1770552051OtherBLUE SHIELD
IAI12158Medicare ID - Type Unspecified
ILF400272670Medicare PIN
IAQ16762Medicare UPIN
IAIB1436032Medicare PIN