Provider Demographics
NPI:1497156327
Name:HANNON, GRACE E (PA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:HANNON
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:6301 S MCCLINTOCK DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3392
Mailing Address - Country:US
Mailing Address - Phone:480-214-2300
Mailing Address - Fax:480-214-2301
Practice Address - Street 1:2550 E GUADALUPE RD STE 115
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5114
Practice Address - Country:US
Practice Address - Phone:480-632-1544
Practice Address - Fax:480-632-1533
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2019-07-08
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Provider Licenses
StateLicense IDTaxonomies
AZ5787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ965194Medicaid