1194151423 NPI number — MRS. TINA GAYLE HANNER FNP-C

Table of content: MRS. TINA GAYLE HANNER FNP-C (NPI 1194151423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194151423 NPI number — MRS. TINA GAYLE HANNER FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANNER
Provider First Name:
TINA
Provider Middle Name:
GAYLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194151423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-6098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-324-6450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
719 W COKE RD
Provider Second Line Business Practice Location Address:
BLDG. 4, STE 6
Provider Business Practice Location Address City Name:
WINNSBORO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75494-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-342-3760
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  661717 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 75-2616977-066 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2771569-005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01280555 . This is a "RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-043 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01812452 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 328273302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8583ND . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 328273301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8638MC . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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