Healthcare Provider Details

I. General information

NPI: 1063457265
Provider Name (Legal Business Name): MICHELLE N HAGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33290 BAINBRIDGE RD
SOLON OH
44139-2802
US

IV. Provider business mailing address

1595 HAMPTON CT
PAINESVILLE OH
44077-5022
US

V. Phone/Fax

Practice location:
  • Phone: 440-600-7675
  • Fax:
Mailing address:
  • Phone: 440-413-6272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.002361
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: