Provider Demographics
NPI:1699321240
Name:RICO, HANNAH (PA-C)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:RICO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:BRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6163
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-2500
Practice Address - Fax:682-885-2510
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12881363A00000X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA12881OtherTEXAS PHYSICIAN ASSISTANT STATE LICENSE
1163025OtherNCCPA