Provider Demographics
NPI:1730155870
Name:HAGAN, WYATT
Entity type:Individual
Prefix:DR
First Name:WYATT
Middle Name:
Last Name:HAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 SIOUX POINT ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5077
Mailing Address - Country:US
Mailing Address - Phone:605-232-1711
Mailing Address - Fax:
Practice Address - Street 1:711 SIOUX POINT ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5077
Practice Address - Country:US
Practice Address - Phone:605-232-1711
Practice Address - Fax:605-232-2040
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD944111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS7788Medicare PIN