Healthcare Provider Details

I. General information

NPI: 1205406931
Provider Name (Legal Business Name): CARSON LEE HAGOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 CHAPEL HILL TRL
FULTONDALE AL
35068-6077
US

IV. Provider business mailing address

354 CHAPEL HILL TRL
FULTONDALE AL
35068-6077
US

V. Phone/Fax

Practice location:
  • Phone: 931-309-0211
  • Fax:
Mailing address:
  • Phone: 931-309-0211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number34060
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: