Healthcare Provider Details

I. General information

NPI: 1841263175
Provider Name (Legal Business Name): THOMAS B. HAGELBERGER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE CHOCTAW WAY CHOCTAW NATION HEALTH CARE CENTER
TALIHINA OK
74571-0000
US

IV. Provider business mailing address

54756 LAWSON LANE
TALIHINA OK
74571-0000
US

V. Phone/Fax

Practice location:
  • Phone: 918-567-7000
  • Fax:
Mailing address:
  • Phone: 918-567-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5193
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: