Provider Demographics
NPI:1285800110
Name:JACQUELINE G. HANCOCK, CRNA, PA
Entity type:Organization
Organization Name:JACQUELINE G. HANCOCK, CRNA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:KGWEN
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:410-239-7074
Mailing Address - Street 1:3245 FARM LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21102-1780
Mailing Address - Country:US
Mailing Address - Phone:410-239-7074
Mailing Address - Fax:
Practice Address - Street 1:3245 FARM LN
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MD
Practice Address - Zip Code:21102-1780
Practice Address - Country:US
Practice Address - Phone:410-893-1172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR036423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
050MOtherMEDICARE GROUP ID
MD218011100Medicaid