Provider Demographics
NPI:1770106619
Name:PEACOCK, HANNAH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HANNAH
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:HOLASEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2541 NW 56TH STREET
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-464-2015
Mailing Address - Fax:
Practice Address - Street 1:1111 N LEE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2600
Practice Address - Country:US
Practice Address - Phone:405-594-5848
Practice Address - Fax:405-594-5847
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK76077OtherOBN CERTIFICATE OF REGISTRATION NO.
OK3211OtherSTATE LICENSE NUMBER
OK3211OtherSTATE LICENSE NUMBER