Provider Demographics
NPI:1053350751
Name:HAGAN, LARRY LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LYNN
Last Name:HAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-2019
Mailing Address - Country:US
Mailing Address - Phone:304-529-6100
Mailing Address - Fax:304-529-0229
Practice Address - Street 1:1001 20TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-2019
Practice Address - Country:US
Practice Address - Phone:304-529-6100
Practice Address - Fax:304-529-0229
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22558207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007713Medicaid
OHL2725779Medicaid
WV0011693000Medicaid
WVHA4202081Medicare PIN
KY5184Medicare PIN
WVI68547Medicare UPIN
WV0011693000Medicaid
WVP00368093Medicare PIN
WVCF8298Medicare PIN
WVTR9263351Medicare PIN