Provider Demographics
NPI:1316971229
Name:HANNA, SAM (PT)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:HANNA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 FOREST AVE
Mailing Address - Street 2:SUITE 430
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2044
Mailing Address - Country:US
Mailing Address - Phone:718-618-0052
Mailing Address - Fax:718-534-4135
Practice Address - Street 1:5910 JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5156
Practice Address - Country:US
Practice Address - Phone:917-545-9249
Practice Address - Fax:718-534-4135
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist