Provider Demographics
NPI:1124194618
Name:HANNAWAY, BASSAM (MPT)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:HANNAWAY
Suffix:
Gender:M
Credentials:MPT
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 8520
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-1720
Mailing Address - Country:US
Mailing Address - Phone:909-557-1600
Mailing Address - Fax:909-557-1740
Practice Address - Street 1:1901 W LUGONIA AVE STE 130
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-9704
Practice Address - Country:US
Practice Address - Phone:909-557-1600
Practice Address - Fax:909-557-1740
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29668ZOtherMEDICARE PTAN
CAZZZ29668ZOtherMEDICARE PTAN
CAP89398Medicare UPIN