Basic Information
| Provider Information | |||||||||
| NPI: | 1700191426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAGEN | ||||||||
| FirstName: | DEANDRA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808959555 | ||||||||
| FaxNumber: | 4808959494 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808959555 | ||||||||
| FaxNumber: | 4808959494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2010 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | RN128051 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 236276 | 05 | AZ | MEDICAID |