=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720305535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA SURGEONS ASSISTANT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2010
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4369 E HARTFORD AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-568-7294
-----------------------------------------------------
Fax | 602-867-4992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4369 E HARTFORD AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-568-7294
-----------------------------------------------------
Fax | 602-867-4992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | HAITHAM M HANNA
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 602-568-7294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 1013800
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------