Provider Demographics
NPI:1053752782
Name:HAGEN, KRISTOFFER L (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTOFFER
Middle Name:L
Last Name:HAGEN
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 1:3420 JACKSON ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-8144
Mailing Address - Country:US
Mailing Address - Phone:920-426-2211
Mailing Address - Fax:
Practice Address - Street 1:500 S OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7944
Practice Address - Country:US
Practice Address - Phone:920-223-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI160648-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered