Provider Demographics
NPI:1043834633
Name:SELDOMRIDGE, HANNAH (PA-C)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:SELDOMRIDGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:4633 BRAMBLETON AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3410
Practice Address - Country:US
Practice Address - Phone:540-968-7368
Practice Address - Fax:844-212-0402
Is Sole Proprietor?:No
Enumeration Date:2020-05-30
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007309363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical