Basic Information
Provider Information | |||||||||
NPI: | 1659618197 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANEY | ||||||||
FirstName: | JON | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 610 E 24TH ST | ||||||||
Address2: |   | ||||||||
City: | TISHOMINGO | ||||||||
State: | OK | ||||||||
PostalCode: | 734603245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802728266 | ||||||||
FaxNumber: | 5803712451 | ||||||||
Practice Location | |||||||||
Address1: | 1921 STONECIPHER DR | ||||||||
Address2: |   | ||||||||
City: | ADA | ||||||||
State: | OK | ||||||||
PostalCode: | 748203439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5804214570 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2013 | ||||||||
LastUpdateDate: | 11/01/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 2206 | 01 | OK | STATE LICENSE | OTHER | PHS000 | 01 | OK | IHS | OTHER |