Basic Information
| Provider Information | |||||||||
| NPI: | 1649458423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860472169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860472169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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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 | 207Q00000X | 36854 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1427335140 | 05 | AZ | MEDICAID | 8HI949 | 01 | CBQ | OTHER | 407506 | 05 | AZ | MEDICAID |