Provider Demographics
NPI:1285300475
Name:HAGEN, ERIN MARINA (PA-C)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MARINA
Last Name:HAGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 NW 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1662 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2502
Practice Address - Country:US
Practice Address - Phone:503-684-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11373207N00000X, 363A00000X
ORPA212971363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty