Provider Demographics
NPI:1043811201
Name:HANNIBAL, JASON ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:HANNIBAL
Suffix:
Gender:M
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:PSC 455 BOX 208
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96540
Mailing Address - Country:US
Mailing Address - Phone:671-344-9340
Mailing Address - Fax:
Practice Address - Street 1:50 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-344-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant