Provider Demographics
NPI:1477530186
Name:HANNA, BECKY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:JO
Last Name:HANNA
Suffix:
Gender:F
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:PO BOX 19670
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9670
Mailing Address - Country:US
Mailing Address - Phone:217-757-8100
Mailing Address - Fax:217-757-8161
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-757-8100
Practice Address - Fax:217-757-8161
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001617363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK35642Medicare PIN
IL208343Medicare PIN
P38827Medicare UPIN