Provider Demographics
NPI:1235678418
Name:HAGAN, JOSIE SUZANNE
Entity type:Individual
Prefix:
First Name:JOSIE
Middle Name:SUZANNE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 PETERSON POINT RD
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-8268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 WORKMAN TER
Practice Address - Street 2:
Practice Address - City:LINCOL
Practice Address - State:ME
Practice Address - Zip Code:04457
Practice Address - Country:US
Practice Address - Phone:207-794-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4827225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant