Healthcare Provider Details

I. General information

NPI: 1083601868
Provider Name (Legal Business Name): ROBERT DEAN HANNA P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 N COMMERCE ST STE 203
ARDMORE OK
73401-1859
US

IV. Provider business mailing address

7800 NW 85TH TER
OKLAHOMA CITY OK
73132-3385
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-6555
  • Fax: 580-226-4617
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number947
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: