Provider Demographics
NPI:1104681758
Name:HAGERSTROM, ROBERT FREDERICK
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:FREDERICK
Last Name:HAGERSTROM
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 1:1005 SHAWMUT ST S
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-2826
Mailing Address - Country:US
Mailing Address - Phone:952-210-6451
Mailing Address - Fax:
Practice Address - Street 1:1005 SHAWMUT ST S
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2826
Practice Address - Country:US
Practice Address - Phone:952-210-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care