Provider Demographics
NPI:1912650151
Name:HASSAN, MARIAM ADAM
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:ADAM
Last Name:HASSAN
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 1:5386 SNAPFINGER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-4027
Mailing Address - Country:US
Mailing Address - Phone:470-880-8080
Mailing Address - Fax:
Practice Address - Street 1:858 SUSANNAH CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-6186
Practice Address - Country:US
Practice Address - Phone:614-599-5692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA272797363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care