Provider Demographics
NPI:1811997000
Name:HANAUSKA, JODI (PA-C)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:HANAUSKA
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 1:3355 RIVERBEND DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-8800
Mailing Address - Country:US
Mailing Address - Phone:541-686-8353
Mailing Address - Fax:541-681-3078
Practice Address - Street 1:3355 RIVERBEND DR
Practice Address - Street 2:SUITE 400
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-686-8353
Practice Address - Fax:541-681-3078
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00714363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP35014Medicare UPIN
OR109842Medicare ID - Type Unspecified