Basic Information
Provider Information | |||||||||
NPI: | 1164772349 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAGEN | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 130 EDINBURGH SOUTH DR | ||||||||
Address2: | SUITE 208 | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275117902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194594743 | ||||||||
FaxNumber: | 9194675299 | ||||||||
Practice Location | |||||||||
Address1: | 2130 FOREST HILLS RD W | ||||||||
Address2: | SUITE A | ||||||||
City: | WILSON | ||||||||
State: | NC | ||||||||
PostalCode: | 278933680 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2522659200 | ||||||||
FaxNumber: | 2522378600 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2012 | ||||||||
LastUpdateDate: | 10/04/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 208154 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.