Healthcare Provider Details

I. General information

NPI: 1013893379
Provider Name (Legal Business Name): HANNAH THACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 23RD ST STE 105
ASHLAND KY
41101-2890
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-408-7500
  • Fax: 606-408-6600
Mailing address:
  • Phone: 606-408-9564
  • Fax: 606-408-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.009624RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: