Provider Demographics
NPI:1699765545
Name:HAGEN, GARY (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:HAGEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16229 TEMPLE DR S
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-3462
Mailing Address - Country:US
Mailing Address - Phone:952-935-8556
Mailing Address - Fax:
Practice Address - Street 1:8401 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4488
Practice Address - Country:US
Practice Address - Phone:763-383-4150
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 075186-7367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered