Healthcare Provider Details

I. General information

NPI: 1902342868
Provider Name (Legal Business Name): HANNA MEDICAL CLINIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 LAURA LN STE 105
MIDDLETON WI
53562-1428
US

IV. Provider business mailing address

3207 LAURA LN STE 105
MIDDLETON WI
53562-1428
US

V. Phone/Fax

Practice location:
  • Phone: 608-203-8022
  • Fax: 608-203-8041
Mailing address:
  • Phone: 608-203-8022
  • Fax: 608-203-8041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NICKOLAS HANNA
Title or Position: OWNER
Credential: MD
Phone: 608-208-8022