MEDICARE: SARA J HAGEN PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	208154	NC

General Provider Information

NPI Number	:	1164772349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA J HAGEN PMHNP

Provider Business Mailing Address
First Line	:	130 EDINBURGH SOUTH DR
Second Line	:	SUITE 208
City	:	CARY
State	:	NC
Zip	:	27511-7902
Country	:	US
Telephone Number	:	919-459-4743
Fax Number	:	919-467-5299

Provider Business Practice Location Address
First Line	:	2130 FOREST HILLS RD W
Second Line	:	SUITE A
City	:	WILSON
State	:	NC
Zip	:	27893-3680
Country	:	US
Telephone Number	:	252-265-9200
Fax Number	:	252-237-8600

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2012
Last Update Date	:	10/04/2013

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