Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 2016000454 | MO |
NPI | 1376916478 |
---|---|
Provider Name | Nathan Hagen |
First Address | Saint Louis, MO 63150-4407 |
Second Address | Kansas City, MO 64111-3220 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2015 |
Last Update Date | 08/01/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2009017999 | LICENSE (01) | MO |
2016000454 | NP LICENSE (01) | MO |