Provider Demographics
NPI:1124029624
Name:HANNON, MARTIN A (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:HANNON
Suffix:
Gender:M
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:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:3730 S PINNACLE HILLS PKWY STE 2
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8897
Practice Address - Country:US
Practice Address - Phone:479-464-5599
Practice Address - Fax:479-464-5598
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146500001Medicaid
H54733Medicare UPIN
AR5M066Medicare ID - Type Unspecified