Provider Demographics
NPI:1083463301
Name:MITCHELL, HAGEN
Entity type:Individual
Prefix:
First Name:HAGEN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 HIGHWAY 117
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72466-8524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:AR
Practice Address - Zip Code:72521
Practice Address - Country:US
Practice Address - Phone:870-283-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4654225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant