Healthcare Provider Details

I. General information

NPI: 1689282709
Provider Name (Legal Business Name): HISANO TASEDAN PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2592 N. SANTIAGO BLVD
ORANGE CA
92867-1862
US

IV. Provider business mailing address

2592 N. SANTIAGO BLVD
ORANGE CA
92867-1862
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax: 949-281-5550
Mailing address:
  • Phone: 855-434-7763
  • Fax: 949-281-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: