Healthcare Provider Details

I. General information

NPI: 1811555709
Provider Name (Legal Business Name): KIMBERLY ANN HAGEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 MARNE HWY STE 200A
MOORESTOWN NJ
08057-3128
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-291-8855
  • Fax:
Mailing address:
  • Phone: 856-355-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1163559
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: