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General NPI Number Information
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NPI Number | 1003392770
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Entity Type | Individual
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Provider Name | DEMI ELISABETH HAGEN PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/16/2018
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Last Update Date | 07/17/2024
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Provider Practice Location Address
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Address Line | 8915 W CONNELL AVE
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City | WAUWATOSA
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State | WI
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Zip | 53226-3067
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Country | US
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Telephone | 414-266-2626
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Fax |
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Provider Business Mailing Address
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Address Line | 999 N 92ND ST
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City | WAUWATOSA
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State | WI
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Zip | 53226-4875
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Country | US
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Telephone | 414-266-2000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 4529-23
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License Number State | WI
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