Provider Demographics
NPI:1629451315
Name:HAN, BRENT (DO)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:HAN
Suffix:
Gender:M
Credentials:DO
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 746093
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6093
Mailing Address - Country:US
Mailing Address - Phone:888-702-0617
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:1036 N ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-6600
Practice Address - Country:US
Practice Address - Phone:480-618-0027
Practice Address - Fax:520-300-8059
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15879207Q00000X
NVDO02543207Q00000X
AZ011028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1629451315Medicaid
NVV73854OtherMEDICARE