MEDICARE: HAGEN D SMITH 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	A-1136	NV

General Provider Information

NPI Number	:	1710543624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAGEN D SMITH PTA

Provider Business Mailing Address
First Line	:	1029 BONITOS SUENOS ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-6062
Country	:	US
Telephone Number	:	425-268-0394
Fax Number	:

Provider Business Practice Location Address
First Line	:	7125 GRAND MONTECITO PKWY STE 120
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-0261
Country	:	US
Telephone Number	:	702-515-1540
Fax Number	:

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

Provider Enumeration Date	:	05/15/2019
Last Update Date	:	05/15/2019

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