Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | LL37689 | SC |
Y | 207QS0010X | Family Doctor - Sports Medicine | 37689 | SC |
NPI | 1063894590 |
---|---|
Provider Name | Andrew Hagenauer |
First Address | Greenville, SC 29601-2842 |
Second Address | Seneca, SC 29678-0812 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2015 |
Last Update Date | 05/08/2020 |