Provider Demographics
NPI:1487732855
Name:HANNA, NICKOLAS F (MD)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:F
Last Name:HANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 LAURA LN STE 105
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1428
Mailing Address - Country:US
Mailing Address - Phone:608-203-8022
Mailing Address - Fax:608-203-8041
Practice Address - Street 1:3207 LAURA LN STE 105
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-1428
Practice Address - Country:US
Practice Address - Phone:608-203-8022
Practice Address - Fax:608-203-8041
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50803-20207P00000X, 2083A0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35208300Medicaid
WIK400129752Medicare PIN