Basic Information
| Provider Information | |||||||||
| NPI: | 1063423366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DER HAGEN | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125650 | ||||||||
| Practice Location | |||||||||
| Address1: | 7373 FRANCE AVE S | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528320076 | ||||||||
| FaxNumber: | 9528329881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9413 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 73B61VA | 01 | BLUE CROSS BLUE SHIELD | OTHER | HP45664 | 01 | HEALTHPARTNERS | OTHER | 114933 | 01 | MEDICA | OTHER | 969991018909 | 01 | PREFERREDONE | OTHER | 12339E948 | 01 | UCARE | OTHER |