Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 1307 | WI |
NPI | 1003974411 |
---|---|
Provider Name | Dr. Larry A Hagen |
First Address | Tomahawk, WI 54487 |
Second Address | Tomahawk, WI 54487 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38567600 | (05) | WI |
T62095 | (02) |