Basic Information
| Provider Information | |||||||||
| NPI: | 1205025764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOMBACHER | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12596 86TH PL N | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553693056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633151466 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY RD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200716 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5570 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.