Provider Demographics
NPI:1235311598
Name:HAMIC, MIA FANGUY (PA)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:FANGUY
Last Name:HAMIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:PAIGE
Other - Last Name:FANGUY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 51008
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-1008
Mailing Address - Country:US
Mailing Address - Phone:318-798-9400
Mailing Address - Fax:318-798-3894
Practice Address - Street 1:2727 HEARNE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3931
Practice Address - Country:US
Practice Address - Phone:318-798-9400
Practice Address - Fax:318-798-3894
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200072363A00000X
TXPA04871363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1822191Medicaid
LA57720PC75Medicare PIN