Provider Demographics
NPI:1114967015
Name:HANNA, MARY ETHELDREDA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ETHELDREDA
Last Name:HANNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8563 HARVEST VIEW CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6560
Mailing Address - Country:US
Mailing Address - Phone:410-750-0311
Mailing Address - Fax:
Practice Address - Street 1:202 DUKE OF GLOUCESTER ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1372
Practice Address - Country:US
Practice Address - Phone:540-345-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD44071207L00000X
VA0101036083207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology