Healthcare Provider Details

I. General information

NPI: 1740489970
Provider Name (Legal Business Name): JOHN HAGAN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 LINDEN AVE
BALTIMORE MD
21201-4606
US

IV. Provider business mailing address

PO BOX 64442
BALTIMORE MD
21264-4442
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-8141
  • Fax: 410-328-0177
Mailing address:
  • Phone: 410-328-8040
  • Fax: 443-462-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberR079848
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: