Basic Information
| Provider Information | |||||||||
| NPI: | 1497156327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNON | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 S MCCLINTOCK DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802142300 | ||||||||
| FaxNumber: | 4802142301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 E GUADALUPE RD STE 115 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852345114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806321544 | ||||||||
| FaxNumber: | 4806321533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 07/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5787 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 965194 | 05 | AZ | MEDICAID |