Provider Demographics
NPI:1194353730
Name:HANE, DUSTY RAE (AGACNP)
Entity type:Individual
Prefix:
First Name:DUSTY
Middle Name:RAE
Last Name:HANE
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:DUSTY
Other - Middle Name:RAE
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-757-6042
Mailing Address - Fax:
Practice Address - Street 1:DIAGNOSTIC CLINIC OF LONGVIEW
Practice Address - Street 2:2901 N FOURTH ST
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-758-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145659363LG0600X, 363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner