Provider Demographics
NPI:1922016682
Name:HIRASA, THOMAS H (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:HIRASA
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 1:804 AINSWORTH DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1624
Mailing Address - Country:US
Mailing Address - Phone:928-771-1011
Mailing Address - Fax:928-771-1332
Practice Address - Street 1:804 AINSWORTH DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1624
Practice Address - Country:US
Practice Address - Phone:928-771-1011
Practice Address - Fax:928-771-1332
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37662208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ313724Medicaid
AZ313724Medicaid