Basic Information
| Provider Information | |||||||||
| NPI: | 1093739351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAGEN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175562727 | ||||||||
| FaxNumber: | 4176596874 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175562727 | ||||||||
| FaxNumber: | 4176596874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 36054 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 100038740A | 05 | OK | MEDICAID | P00817793 | 01 | MO | RAIL ROAD MEDICARE | OTHER | 100229330C | 05 | KS | MEDICAID | 1093739351 | 05 | MO | MEDICAID |