1861789562 NPI number — WILLIAM WALLACE HAGAN DPT

Table of content: WILLIAM WALLACE HAGAN DPT (NPI 1861789562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861789562 NPI number — WILLIAM WALLACE HAGAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGAN
Provider First Name:
WILLIAM
Provider Middle Name:
WALLACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861789562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16083 SW UPPER BOONES FERRY RD
Provider Second Line Business Mailing Address:
STE. 300
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
SEQUIM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98382-3236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-683-3710
Provider Business Practice Location Address Fax Number:
360-683-5256
Provider Enumeration Date:
07/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT010281 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT60335571 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1861789562 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01216103 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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