Provider Demographics
NPI:1295836716
Name:HANVEY, MICHAEL JOE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOE
Last Name:HANVEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 BILLARS ST
Mailing Address - Street 2:
Mailing Address - City:SCOTLAND
Mailing Address - State:SD
Mailing Address - Zip Code:57059-2026
Mailing Address - Country:US
Mailing Address - Phone:605-583-2227
Mailing Address - Fax:605-583-6125
Practice Address - Street 1:610 BILLARS ST
Practice Address - Street 2:
Practice Address - City:SCOTLAND
Practice Address - State:SD
Practice Address - Zip Code:57059-2026
Practice Address - Country:US
Practice Address - Phone:605-583-2227
Practice Address - Fax:605-583-6125
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0651363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6829560Medicaid