=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215258033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL FRANCIS HANNON C.M.T./L.M.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2010
-----------------------------------------------------
Last Update Date | 09/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 S RALEIGH ST
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-886-1615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S RALEIGH ST
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-886-1615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | M02198
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0019011694
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------