Provider Demographics
NPI:1437149820
Name:HANNA, JANELLE MARIA (PA C)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:MARIA
Last Name:HANNA
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 SIDEWINDER DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7570
Practice Address - Country:US
Practice Address - Phone:435-649-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO680363A00000X, 363AS0400X
UT335815-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ621020Medicaid
CO60337265Medicaid
NMB3906Medicaid
CO60337265Medicaid
S54877Medicare UPIN
NMB3906Medicaid