Provider Demographics
NPI:1619362761
Name:HANAWAY, AMANDA PHAN (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:PHAN
Last Name:HANAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3186 S MARYLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2317
Mailing Address - Country:US
Mailing Address - Phone:702-697-0082
Mailing Address - Fax:
Practice Address - Street 1:3186 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2317
Practice Address - Country:US
Practice Address - Phone:702-697-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.146509208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.146509Medicaid