Provider Demographics
NPI:1356693634
Name:HAGEN, EVAN MIKEL (ATC, PTA)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:MIKEL
Last Name:HAGEN
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 GREENLAWN ST SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-3736
Mailing Address - Country:US
Mailing Address - Phone:360-701-4573
Mailing Address - Fax:
Practice Address - Street 1:2610 GREENLAWN ST SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-3736
Practice Address - Country:US
Practice Address - Phone:360-701-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60167096225200000X
WAA1 600302392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer