Basic Information
| Provider Information | |||||||||
| NPI: | 1114929106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNA | ||||||||
| FirstName: | WAFAA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221860 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 25319 LITTLE MACK AVE | ||||||||
| Address2: | |||||||||
| City: | ST CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480813370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864474000 | ||||||||
| FaxNumber: | 5864474009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301062012 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3282477 | 05 | MI | MEDICAID |