Basic Information
| Provider Information | |||||||||
| NPI: | 1770552051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGEDORN | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 W 53RD ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528062459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213800 | ||||||||
| FaxNumber: | 5634213810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 W 53RD ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528062459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213800 | ||||||||
| FaxNumber: | 5634213810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 001550 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363AM0700X | 001550 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1770552051 | 01 | IA | BLUE SHIELD | OTHER |