Provider Demographics
NPI:1316261522
Name:HASAN, ANUM MALLICK (PA-C)
Entity type:Individual
Prefix:
First Name:ANUM
Middle Name:MALLICK
Last Name:HASAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HENDERSON ST
Mailing Address - Street 2:APT 330
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102
Mailing Address - Country:US
Mailing Address - Phone:302-562-5246
Mailing Address - Fax:
Practice Address - Street 1:1000 HENDERSON ST
Practice Address - Street 2:APT 330
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102
Practice Address - Country:US
Practice Address - Phone:302-562-5246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10087363A00000X
MDC0005122363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical