Basic Information
| Provider Information | |||||||||
| NPI: | 1487915153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | TAYLOR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435659 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 ELKS POINT RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | ZEPHYR COVE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894488001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7755898950 | ||||||||
| FaxNumber: | 7755881299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207X00000X | A148997 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 17021 | NV | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200445860A | 05 | OK | MEDICAID |