Provider Demographics
NPI:1972838688
Name:HANQUIST, BRADY W (PAC)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:W
Last Name:HANQUIST
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-2001
Mailing Address - Country:US
Mailing Address - Phone:402-228-3436
Mailing Address - Fax:402-223-4515
Practice Address - Street 1:1101 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-2001
Practice Address - Country:US
Practice Address - Phone:402-228-3436
Practice Address - Fax:402-223-4515
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE95373003Medicare PIN