MEDICARE: ARIZONA SURGEONS ASSISTANT PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	1013800	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	Z138269	OTHER	AZ	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1922	OTHER	AZ	AZ MEDICAL BOARD

General Provider Information

NPI Number	:	1720305535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA SURGEONS ASSISTANT PC

Provider Business Mailing Address
First Line	:	4369 E HARTFORD AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2298
Country	:	US
Telephone Number	:	602-568-7294
Fax Number	:	602-867-4992

Provider Business Practice Location Address
First Line	:	4369 E HARTFORD AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2298
Country	:	US
Telephone Number	:	602-568-7294
Fax Number	:	602-867-4992

Authorized Official
Title or Position	:	CEO
Name	:	HAITHAM M HANNA
Credential	:	PA-C
Telephone Number	:	602-568-7294

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	03/07/2023

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