Healthcare Provider Details

I. General information

NPI: 1508807785
Provider Name (Legal Business Name): JAMES ROGER HAGERMAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLEASANT VALLEY RD SUITE 202
OWENSBORO KY
42303-9774
US

IV. Provider business mailing address

1301 PLEASANT VALLEY RD SUITE 202
OWENSBORO KY
42303-9774
US

V. Phone/Fax

Practice location:
  • Phone: 270-417-7500
  • Fax: 270-417-7509
Mailing address:
  • Phone: 270-417-7500
  • Fax: 270-417-7509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA453
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA453
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: