Provider Demographics
NPI:1083601868
Name:HANNA, ROBERT DEAN (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DEAN
Last Name:HANNA
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 1:7800 NW 85TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 N COMMERCE ST
Practice Address - Street 2:STE 203
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1859
Practice Address - Country:US
Practice Address - Phone:580-223-6555
Practice Address - Fax:580-226-4617
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100198770AMedicaid
OK24H616506Medicare PIN
OKS68192Medicare UPIN
OKOKA102019Medicare PIN
OKOK404277Medicare PIN
OK100198770AMedicaid
OKOK402898Medicare PIN