Healthcare Provider Details

I. General information

NPI: 1093090417
Provider Name (Legal Business Name): JESSICA HAGNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 ST. PAUL PLACE WEINBERG BLDG., 4THFLOOR
BALTIMORE MD
21202-2102
US

IV. Provider business mailing address

301 ST. PAUL PLACE MEDICAL STAFF OFFICE
BALTIMORE MD
21202-2102
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9294
  • Fax:
Mailing address:
  • Phone: 410-659-2802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: