Provider Demographics
NPI:1770106619
Name:PEACOCK, HANNAH MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HANNAH
Middle Name:MARIE
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:HANNAH
Other - Middle Name:MARIE
Other - Last Name:HOLASEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2212 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4303
Mailing Address - Country:US
Mailing Address - Phone:405-285-7222
Mailing Address - Fax:405-285-7227
Practice Address - Street 1:2212 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4303
Practice Address - Country:US
Practice Address - Phone:405-285-7222
Practice Address - Fax:405-285-7227
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2025-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3211363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK14670040OtherCAQH
OK200913150AMedicaid
OK3211OtherSTATE LICENSE NUMBER