Provider Demographics
NPI:1710376173
Name:HANNA, STEPHEN M (RPA-C)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:M
Last Name:HANNA
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10506 S. RIVA RIDGE RD.
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-2778
Mailing Address - Fax:315-772-2788
Practice Address - Street 1:10506 S. RIVA RIDGE RD.
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-2778
Practice Address - Fax:315-772-2788
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020702363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant