Provider Demographics
NPI:1124601919
Name:HANNER, NATHAN VINCENT
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:VINCENT
Last Name:HANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17101-2010
Mailing Address - Country:US
Mailing Address - Phone:717-782-3282
Mailing Address - Fax:717-231-8964
Practice Address - Street 1:4201 RIDGEVIEW RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-2882
Practice Address - Country:US
Practice Address - Phone:157-033-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN663547163WC0200X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103901596Medicaid
PA1Q2227OtherMEDICARE