=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457317497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN CASEY HANNA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2006
-----------------------------------------------------
Last Update Date | 12/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 W. CHEROKEE ST
-----------------------------------------------------
City | WAGONER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-485-5514
-----------------------------------------------------
Fax | 918-485-8503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 W. CHEROKEE ST
-----------------------------------------------------
City | WAGONER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-485-5514
-----------------------------------------------------
Fax | 918-485-8503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 21947
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------