Healthcare Provider Details

I. General information

NPI: 1164918991
Provider Name (Legal Business Name): STEVE ENN HAGAN BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 07/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E FOURTH PLAIN BLVD
VANCOUVER WA
98661-3713
US

IV. Provider business mailing address

17600 NE MULTNOMAH DR
PORTLAND OR
97230-6337
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone: 971-703-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number200842477RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: