Provider Demographics
NPI:1457317497
Name:HANNA, BRYAN CASEY (MD)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:CASEY
Last Name:HANNA
Suffix:
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 1:1200 W. CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467
Mailing Address - Country:US
Mailing Address - Phone:918-485-5514
Mailing Address - Fax:918-485-8503
Practice Address - Street 1:1200 W. CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467
Practice Address - Country:US
Practice Address - Phone:918-485-5514
Practice Address - Fax:918-485-8503
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100148930CMedicaid
OK$$$$$$$$$00OtherBCBS
OK242331400Medicare ID - Type Unspecified