Provider Demographics
NPI:1235129099
Name:HANES, RICHARD D (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:HANES
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 1:1000 KINGFISHER HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73150-0059
Mailing Address - Country:US
Mailing Address - Phone:405-375-7847
Mailing Address - Fax:
Practice Address - Street 1:1000 KINGFISHER HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73150-0059
Practice Address - Country:US
Practice Address - Phone:405-375-7847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1346363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200034610AMedicaid
OK24Y622601Medicare PIN
OK200034610AMedicaid
Q19834Medicare UPIN