Provider Demographics
NPI:1073645131
Name:ADEMHIZAM, HAZAM MANSOUR (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:HAZAM
Middle Name:MANSOUR
Last Name:ADEMHIZAM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6744 KNOTT AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2736
Mailing Address - Country:US
Mailing Address - Phone:714-228-0715
Mailing Address - Fax:
Practice Address - Street 1:6744 KNOTT AVE APT 4
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2736
Practice Address - Country:US
Practice Address - Phone:714-228-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19085363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant