Provider Demographics
NPI:1700270394
Name:HASAN, SONYA S
Entity Type:Individual
Prefix:
First Name:SONYA
Middle Name:S
Last Name:HASAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-1357
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:941-629-2365
Practice Address - Street 1:4300 KINGS HWY
Practice Address - Street 2:#500
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2917
Practice Address - Country:US
Practice Address - Phone:239-344-2337
Practice Address - Fax:941-629-2365
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015008000Medicaid