Provider Demographics
NPI:1003362351
Name:HANNA, PETER SAMIR (PA-C)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:SAMIR
Last Name:HANNA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:BOUTROS
Other - Middle Name:S
Other - Last Name:BADAWI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:14 4TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5733
Mailing Address - Country:US
Mailing Address - Phone:704-340-5079
Mailing Address - Fax:
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:704-340-5079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3800207P00000X, 363AM0700X, 207X00000X
WV1990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical