Provider Demographics
NPI:1053692426
Name:HAGER, BRYAN WAYNE (PA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:WAYNE
Last Name:HAGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BROOKSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2573
Mailing Address - Country:US
Mailing Address - Phone:336-462-1267
Mailing Address - Fax:
Practice Address - Street 1:3200 NORTHLINE AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7616
Practice Address - Country:US
Practice Address - Phone:336-273-7900
Practice Address - Fax:336-275-0433
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001002980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant