Healthcare Provider Details

I. General information

NPI: 1275581530
Provider Name (Legal Business Name): GARY ROBERT HANNA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MCCOMB FIELDHOUSE EDINBORO UNIVERSITY
EDINBORO PA
16444-0001
US

IV. Provider business mailing address

110 HOLLYWOOD BLVD
GREENVILLE PA
16125-1320
US

V. Phone/Fax

Practice location:
  • Phone: 814-732-2776
  • Fax: 814-732-2857
Mailing address:
  • Phone: 724-588-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT000255A
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: