Provider Demographics
NPI:1023765955
Name:KING, HANNA REVEA (PA)
Entity type:Individual
Prefix:
First Name:HANNA
Middle Name:REVEA
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HANNA
Other - Middle Name:REVEA
Other - Last Name:CULVER - DEWEES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1929 W FILLMORE ST BLDG C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85009-3812
Mailing Address - Country:US
Mailing Address - Phone:602-258-6008
Mailing Address - Fax:602-258-8388
Practice Address - Street 1:1929 W FILLMORE ST BLDG C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-3812
Practice Address - Country:US
Practice Address - Phone:602-258-6008
Practice Address - Fax:602-258-8388
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTP9040363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical