Healthcare Provider Details

I. General information

NPI: 1063825768
Provider Name (Legal Business Name): SAMIR HASAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 05/12/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 S BANNOCK ST
ENGLEWOOD CO
80110-2432
US

IV. Provider business mailing address

3333 S BANNOCK ST STE 150
ENGLEWOOD CO
80110-2514
US

V. Phone/Fax

Practice location:
  • Phone: 720-677-5649
  • Fax:
Mailing address:
  • Phone: 720-677-5649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number301986
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number65914
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: