Provider Demographics
NPI:1508853375
Name:HANISAK, JILL L (CRNA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:L
Last Name:HANISAK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE #301
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6258
Mailing Address - Country:US
Mailing Address - Phone:610-402-9080
Mailing Address - Fax:610-402-9029
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:610-402-9080
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN240246L163W00000X
PA046891367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1546038OtherGATEWAY
PA0017673800006Medicaid
PA03224201OtherCAPITAL ADVANTAGE
PA1343791OtherHIGHMARK
PA1343791OtherKHP CENTRAL
PA11776573OtherCAQH
PA1343791OtherFIRST PRIORITY
PA2036405000OtherINDEP. BLUE CROSS
PA82851OtherGEISINGER
PA9573465OtherAETNA
PA1343791OtherKHP CENTRAL
PA9573465OtherAETNA
PA430070502Medicare PIN