Healthcare Provider Details

I. General information

NPI: 1790039386
Provider Name (Legal Business Name): STEFAN HANNEVIG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2012
Last Update Date: 11/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 FRANKLIN SQUARE DR
BALTIMORE MD
21237-3901
US

IV. Provider business mailing address

644 SHREWSBURY COMMONS AVE
SHREWSBURY PA
17361-1617
US

V. Phone/Fax

Practice location:
  • Phone: 443-777-7000
  • Fax:
Mailing address:
  • Phone: 304-893-2295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: