Basic Information
Provider Information | |||||||||
NPI: | 1477535755 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANNEN | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FREE | ||||||||
OtherFirstName: | PAMELA | ||||||||
OtherMiddleName: | MARY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 19070 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543079070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204964700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1032 S CESAR E CHAVEZ DR | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532042203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146721353 | ||||||||
FaxNumber: | 4146724265 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2005 | ||||||||
LastUpdateDate: | 11/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1926 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1477535755 | 01 | WI | NPI | OTHER | MF1305386 | 01 | WI | DEA | OTHER | 42880300 | 05 | WI |   | MEDICAID |