Healthcare Provider Details

I. General information

NPI: 1003994484
Provider Name (Legal Business Name): MARY SUE HAGER MS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S FENWAY ST STE 202
CASPER WY
82601-3053
US

IV. Provider business mailing address

301 S FENWAY ST STE 202
CASPER WY
82601-3053
US

V. Phone/Fax

Practice location:
  • Phone: 307-577-7737
  • Fax: 307-577-0049
Mailing address:
  • Phone: 307-577-7737
  • Fax: 307-577-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16044197
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: