Basic Information
Provider Information | |||||||||
NPI: | 1164653002 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANNASCH | ||||||||
FirstName: | MOLLY | ||||||||
MiddleName: | LAUREN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.- C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6971 | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685060971 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024867083 | ||||||||
FaxNumber: | 4024346047 | ||||||||
Practice Location | |||||||||
Address1: | 1550 S 70TH ST | ||||||||
Address2: | SUITE 202 | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685061576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023288833 | ||||||||
FaxNumber: | 4023282921 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2009 | ||||||||
LastUpdateDate: | 12/04/2015 | ||||||||
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 | 363AS0400X |   |   | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 1457 | NE | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | N/A | 01 | NE | MIDLANDS CHOICE | OTHER | 24384 | 01 | NE | BCBS | OTHER | N/A | 01 | NE | HUMANA | OTHER | N/A | 01 | NE | COVENTRY | OTHER |