MEDICARE: MRS. HEIDI J HAGEN PTA

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	225200000X	Physical Therapy Assistant	0213A	AZ

General Provider Information

NPI Number	:	1518020726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEIDI J HAGEN PTA

Provider Business Mailing Address
First Line	:	3024 N SILVERADO
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-1040
Country	:	US
Telephone Number	:	602-697-1085
Fax Number	:

Provider Business Practice Location Address
First Line	:	2835 E BROWN RD
Second Line	:	SUITE 101
City	:	MESA
State	:	AZ
Zip	:	85213-5470
Country	:	US
Telephone Number	:	480-807-6644
Fax Number	:

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	01/21/2011

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