Provider Demographics
NPI:1659618197
Name:HANEY, JON W (PA-C)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:W
Last Name:HANEY
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 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-272-8266
Mailing Address - Fax:580-371-2451
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-421-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2206OtherSTATE LICENSE
OKPHS000OtherIHS