Healthcare Provider Details

I. General information

NPI: 1790872000
Provider Name (Legal Business Name): BRYAN M HAGEN DNP, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 NE 4TH ST STE 100
BEND OR
97701-4646
US

IV. Provider business mailing address

685 SE 3RD ST
BEND OR
97702-1754
US

V. Phone/Fax

Practice location:
  • Phone: 541-617-7365
  • Fax:
Mailing address:
  • Phone: 541-617-7365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201250173NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number201042999RN
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500689745
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: