Basic Information
| Provider Information | |||||||||
| NPI: | 1720558786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGLUND | ||||||||
| FirstName: | BREANNA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | HUNTERTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467480670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 2607483650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2512 E DUPONT RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 2607483651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2018 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 10002628A | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.