Provider Demographics
NPI:1083105449
Name:HANNER, MARVIN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:DOUGLAS
Last Name:HANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DOUGLAS
Other - Middle Name:
Other - Last Name:HANNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-6583
Practice Address - Fax:417-269-6573
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT215112207P00000X
MO2019042253207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine