Provider Demographics
NPI:1730271131
Name:HA, AN DAN (RPT)
Entity type:Individual
Prefix:
First Name:AN DAN
Middle Name:
Last Name:HA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CLOVE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3648
Mailing Address - Country:US
Mailing Address - Phone:718-816-6500
Mailing Address - Fax:718-816-4677
Practice Address - Street 1:7524 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3104
Practice Address - Country:US
Practice Address - Phone:718-816-6500
Practice Address - Fax:718-816-4677
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2023-05-10
Deactivation Date:2022-07-22
Deactivation Code:
Reactivation Date:2022-08-19
Provider Licenses
StateLicense IDTaxonomies
FLPT22783225100000X
NY050289208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0891659400Medicaid