Provider Demographics
NPI:1902134216
Name:LOVALLO, HANNAH (PA-C)
Entity type:Individual
Prefix:MS
First Name:HANNAH
Middle Name:
Last Name:LOVALLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6600
Mailing Address - Country:US
Mailing Address - Phone:315-637-7800
Mailing Address - Fax:315-637-7808
Practice Address - Street 1:4103 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6600
Practice Address - Country:US
Practice Address - Phone:315-637-7800
Practice Address - Fax:315-637-7808
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054237363AM0700X
NY015364363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03488011Medicaid
NYJ400066162Medicare PIN