Provider Demographics
NPI:1417022377
Name:HANNAN, JOSEPH E JR (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:E
Last Name:HANNAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J. E. PATRICK
Other - Middle Name:
Other - Last Name:HANNAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2235 CHALLENGER WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5458
Mailing Address - Country:US
Mailing Address - Phone:707-528-7262
Mailing Address - Fax:707-576-1964
Practice Address - Street 1:2235 CHALLENGER WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5458
Practice Address - Country:US
Practice Address - Phone:707-528-7262
Practice Address - Fax:707-576-1964
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC-352672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC 35267OtherMEDICAL LICENSE NUMBER
CAC 35267OtherMEDICAL LICENSE NUMBER
A 35916Medicare UPIN