Provider Demographics
NPI:1801825724
Name:HAN, ALLEN C (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:C
Last Name:HAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 E OVERLAND ROAD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-343-3976
Mailing Address - Fax:208-333-9942
Practice Address - Street 1:3875 E OVERLAND ROAD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-343-3976
Practice Address - Fax:208-333-9942
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM57322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002586000Medicaid
E25411Medicare UPIN
ID002586000Medicaid