Healthcare Provider Details

I. General information

NPI: 1164164521
Provider Name (Legal Business Name): HAROON KISANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5652 E BASELINE RD
MESA AZ
85206-4713
US

IV. Provider business mailing address

2040 S ALMA SCHOOL RD STE 1-190
CHANDLER AZ
85286-7075
US

V. Phone/Fax

Practice location:
  • Phone: 480-200-4354
  • Fax:
Mailing address:
  • Phone: 480-200-4354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number14289915-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number74393
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: