Healthcare Provider Details

I. General information

NPI: 1972585404
Provider Name (Legal Business Name): GERALYN C HAHNE PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 N. MAIN
ISABEL SD
57633-0097
US

IV. Provider business mailing address

PO BOX 97
ISABEL SD
57633-0097
US

V. Phone/Fax

Practice location:
  • Phone: 605-466-2120
  • Fax: 605-466-2190
Mailing address:
  • Phone: 605-466-2120
  • Fax: 605-466-2190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0496
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4323772
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: