Provider Demographics
NPI:1811986672
Name:HAGSTROM, LIV S (PA-C)
Entity type:Individual
Prefix:MS
First Name:LIV
Middle Name:S
Last Name:HAGSTROM
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 1:75 FRANCIS ST
Mailing Address - Street 2:CARDIOVASCULAR DIVISION
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-733-9667
Mailing Address - Fax:
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-829-8618
Practice Address - Fax:310-829-8607
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004777363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8413650Medicaid
WA8800425Medicare ID - Type Unspecified
WAQ30613Medicare UPIN