Provider Demographics
NPI:1841263175
Name:HAGELBERGER, THOMAS B (PA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:B
Last Name:HAGELBERGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:54756 LAWSON LANE
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0000
Mailing Address - Country:US
Mailing Address - Phone:918-567-5380
Mailing Address - Fax:
Practice Address - Street 1:ONE CHOCTAW WAY
Practice Address - Street 2:CHOCTAW NATION HEALTH CARE CENTER
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-0000
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS45891Medicare UPIN