Provider Demographics
NPI:1730558172
Name:FORDRED, HANNAH (PA)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:FORDRED
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4587
Mailing Address - Country:US
Mailing Address - Phone:850-763-0036
Mailing Address - Fax:
Practice Address - Street 1:2100 STATE AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4587
Practice Address - Country:US
Practice Address - Phone:850-763-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057844363AM0700X
CO4603363AM0700X
FL9115156363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113338100Medicaid
CO32130261Medicaid