Healthcare Provider Details

I. General information

NPI: 1477530186
Provider Name (Legal Business Name): BECKY JO HANNA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

PO BOX 19670
SPRINGFIELD IL
62794-9670
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-8100
  • Fax: 217-757-8161
Mailing address:
  • Phone: 217-757-8100
  • Fax: 217-757-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-001617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: