Provider Demographics
NPI:1043516511
Name:HASAN, ADEY A A (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEY
Middle Name:A A
Last Name:HASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1779
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-1779
Mailing Address - Country:US
Mailing Address - Phone:904-829-8300
Mailing Address - Fax:
Practice Address - Street 1:204 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5135
Practice Address - Country:US
Practice Address - Phone:904-829-8300
Practice Address - Fax:904-829-8310
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122715207R00000X, 207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01368151OtherRR MEDICARE
TNQ006171Medicaid
NC1043516511Medicaid
VA1043516511Medicaid
KY7100305080Medicaid
TN103I112106Medicare PIN