Healthcare Provider Details

I. General information

NPI: 1740441211
Provider Name (Legal Business Name): GREG HAGEN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 9TH ST SE
ROCHESTER MN
55904-6425
US

IV. Provider business mailing address

210 9TH ST SE
ROCHESTER MN
55904-6425
US

V. Phone/Fax

Practice location:
  • Phone: 507-529-6617
  • Fax:
Mailing address:
  • Phone: 507-529-6617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR0991818
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: