Provider Demographics
NPI:1629283510
Name:HANNA, KENNY E JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:E
Last Name:HANNA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8545 W WARM SPRINGS RD STE A4-343
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:702-933-8671
Practice Address - Street 1:319 S BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1701
Practice Address - Country:US
Practice Address - Phone:818-240-0006
Practice Address - Fax:818-240-0038
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV146602086S0105X
CAC150292086S0105X
AZ46884207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV111691Medicare PIN