Provider Demographics
NPI:1508158841
Name:HANNER, TESS NICOLE (DO)
Entity Type:Individual
Prefix:DR
First Name:TESS
Middle Name:NICOLE
Last Name:HANNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 E 27TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-5908
Mailing Address - Country:US
Mailing Address - Phone:918-899-8159
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-899-8159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5223207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200462100AMedicaid