1235311598 NPI number — MIA FANGUY HAMIC PA

Table of content: MIA FANGUY HAMIC PA (NPI 1235311598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235311598 NPI number — MIA FANGUY HAMIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMIC
Provider First Name:
MIA
Provider Middle Name:
FANGUY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FANGUY
Provider Other First Name:
MIA
Provider Other Middle Name:
PAIGE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235311598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51008
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71135-1008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-798-9400
Provider Business Mailing Address Fax Number:
318-798-3894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2727 HEARNE AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71103-3931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-798-9400
Provider Business Practice Location Address Fax Number:
318-798-3894
Provider Enumeration Date:
11/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA.200072 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA04871 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1822191 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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