Provider Demographics
NPI:1801013065
Name:HALL, NANCY L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:L
Last Name:HALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3926 NEW VISION DR
Mailing Address - Street 2:BLDG H
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-266-8213
Mailing Address - Fax:260-458-5658
Practice Address - Street 1:4466 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3170
Practice Address - Country:US
Practice Address - Phone:810-733-1200
Practice Address - Fax:810-733-3130
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215930490OtherTYPE 2 NPI
MI0N45090OtherGRP MEDICARE NUMBER
MI0N45090028Medicare PIN