Provider Demographics
NPI:1134135924
Name:HAYRE-KWAN, SURANI (FNP)
Entity Type:Individual
Prefix:
First Name:SURANI
Middle Name:
Last Name:HAYRE-KWAN
Suffix:
Gender:F
Credentials:FNP
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 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-869-5977
Mailing Address - Fax:707-869-5983
Practice Address - Street 1:16319 THIRD STREET
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446
Practice Address - Country:US
Practice Address - Phone:707-869-2849
Practice Address - Fax:707-869-1477
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP504240363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP504240OtherSTATE LICENSE NUMBER
ZZZ73222ZOtherMEDICARE PART B
CA1356344758Medicaid
CAQ15449Medicare UPIN
CA1356344758Medicaid