Healthcare Provider Details

I. General information

NPI: 1568945764
Provider Name (Legal Business Name): LA-SHO'NDRA HAGIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 SAINT SEBASTIAN WAY STE 311
AUGUSTA GA
30901
US

IV. Provider business mailing address

PO BOX 925
AUGUSTA GA
30903-0925
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-3473
  • Fax: 706-724-3493
Mailing address:
  • Phone: 706-774-7263
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN139299
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: