Provider Demographics
NPI:1255546115
Name:ALWAN, SALLY A (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:ALWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:A
Other - Last Name:AL-ABDULLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 HITCHCOCK WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-4125
Mailing Address - Country:US
Mailing Address - Phone:603-695-2500
Mailing Address - Fax:
Practice Address - Street 1:100 HITCHCOCK WAY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-4125
Practice Address - Country:US
Practice Address - Phone:603-695-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30209390Medicaid
NH30209390Medicaid