Provider Demographics
NPI:1578093258
Name:HAGEN, KYLE JAY (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JAY
Last Name:HAGEN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4321
Mailing Address - Country:US
Mailing Address - Phone:414-805-5320
Mailing Address - Fax:414-805-5323
Practice Address - Street 1:10000 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4321
Practice Address - Country:US
Practice Address - Phone:414-805-5320
Practice Address - Fax:414-805-5323
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4038363A00000X
WI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1578093258Medicaid