MEDICARE: SELAM W HAGOS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	95298359	CA

General Provider Information

NPI Number	:	1336003912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELAM W HAGOS RN

Provider Business Mailing Address
First Line	:	7983 HEMINGWAY CT
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-5492
Country	:	US
Telephone Number	:	323-603-1885
Fax Number	:

Provider Business Practice Location Address
First Line	:	7983 HEMINGWAY CT
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-5492
Country	:	US
Telephone Number	:	323-603-1885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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