Provider Demographics
NPI:1831185024
Name:HAGAN, CLAYTON PATRICK (CRNA)
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:PATRICK
Last Name:HAGAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:
Practice Address - Street 1:5454 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1931
Practice Address - Country:US
Practice Address - Phone:219-933-2270
Practice Address - Fax:219-852-2515
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161888A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200073800Medicaid
INCA9280LMedicare ID - Type Unspecified