Healthcare Provider Details

I. General information

NPI: 1578093258
Provider Name (Legal Business Name): KYLE JAY HAGEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W BLUEMOUND RD
WAUWATOSA WI
53226-4321
US

IV. Provider business mailing address

10000 W BLUEMOUND RD
WAUWATOSA WI
53226-4321
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5320
  • Fax: 414-805-5323
Mailing address:
  • Phone: 414-805-5320
  • Fax: 414-805-5323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4038
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: