Provider Demographics
NPI:1043084395
Name:HAIDAR, HUSSEIN
Entity type:Individual
Prefix:
First Name:HUSSEIN
Middle Name:
Last Name:HAIDAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13555 W MCDOWELL RD STE 205
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2626
Mailing Address - Country:US
Mailing Address - Phone:623-295-1190
Mailing Address - Fax:
Practice Address - Street 1:13555 W MCDOWELL RD STE 205
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2626
Practice Address - Country:US
Practice Address - Phone:623-295-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704365610363LF0000X
AZ270547363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily