Healthcare Provider Details

I. General information

NPI: 1487915153
Provider Name (Legal Business Name): JONATHAN TAYLOR HAGEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 ELKS POINT RD STE 200
ZEPHYR COVE NV
89448-8001
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 775-589-8950
  • Fax: 775-588-1299
Mailing address:
  • Phone: 530-543-5659
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA148997
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number17021
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: