Basic Information
| Provider Information | |||||||||
| NPI: | 1467433201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANNA | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 824 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTEVIDEO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562651629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202698877 | ||||||||
| FaxNumber: | 3202698186 | ||||||||
| Practice Location | |||||||||
| Address1: | 824 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTEVIDEO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562651629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202698877 | ||||||||
| FaxNumber: | 3202698186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 12/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21169 | NE | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 43944 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 276903400 | 05 | MN | MEDICAID |