Provider Demographics
NPI:1073119780
Name:HASANOVIC, TEA (PA-C)
Entity Type:Individual
Prefix:
First Name:TEA
Middle Name:
Last Name:HASANOVIC
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 1:2101 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2132
Mailing Address - Country:US
Mailing Address - Phone:208-452-5999
Mailing Address - Fax:
Practice Address - Street 1:2101 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2132
Practice Address - Country:US
Practice Address - Phone:208-452-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant