Basic Information
| Provider Information | |||||||||
| NPI: | 1164855086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNA | ||||||||
| FirstName: | ELIJAH | ||||||||
| MiddleName: | LIVINGSTON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 7133 NITTANY VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | MILL HALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707267992 | ||||||||
| FaxNumber: | 5707262242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 06/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA056281 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103272375 | 05 | PA | MEDICAID |