Provider Demographics
NPI:1841719390
Name:HAGAN, KYLE (PA0C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HAGAN
Suffix:
Gender:M
Credentials:PA0C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2205
Mailing Address - Country:US
Mailing Address - Phone:901-759-5443
Mailing Address - Fax:901-759-3196
Practice Address - Street 1:1400 S GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2205
Practice Address - Country:US
Practice Address - Phone:901-759-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08402771Medicaid
TNQ061378Medicaid