Provider Demographics
NPI:1710382601
Name:RAZA, HASAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:HASAN
Middle Name:
Last Name:RAZA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 S RIVER ST
Mailing Address - Street 2:SUITE 254
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3860
Mailing Address - Country:US
Mailing Address - Phone:608-755-5260
Mailing Address - Fax:
Practice Address - Street 1:17 S RIVER ST
Practice Address - Street 2:SUITE 254
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3860
Practice Address - Country:US
Practice Address - Phone:608-755-5260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI346123363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710382601Medicaid