Healthcare Provider Details

I. General information

NPI: 1639522121
Provider Name (Legal Business Name): ALI HASAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 S ALAMEDA ST
CORPUS CHRISTI TX
78411-1721
US

IV. Provider business mailing address

3533 S ALAMEDA ST
CORPUS CHRISTI TX
78411-1721
US

V. Phone/Fax

Practice location:
  • Phone: 361-694-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberS5918
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberS5918
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: