Provider Demographics
NPI:1699428771
Name:HAGEN, LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
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 1:2053 FOUNTAIN PROFESSIONAL CT STE B
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-5109
Mailing Address - Country:US
Mailing Address - Phone:850-530-0225
Mailing Address - Fax:850-522-8354
Practice Address - Street 1:3089 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3216
Practice Address - Country:US
Practice Address - Phone:850-203-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-30
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115599363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical