Healthcare Provider Details

I. General information

NPI: 1407171879
Provider Name (Legal Business Name): ANDREA LYNNE HAGEMAN CST/ CFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 S CLIFTON AVE SUITE 250
WICHITA KS
67218-2900
US

IV. Provider business mailing address

818 N EMPORIA ST SUITE 200
WICHITA KS
67214-3729
US

V. Phone/Fax

Practice location:
  • Phone: 316-686-1991
  • Fax:
Mailing address:
  • Phone: 316-263-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number92312
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: