Basic Information
| Provider Information | |||||||||
| NPI: | 1760674295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANOSSIAN | ||||||||
| FirstName: | ABRAHAM | ||||||||
| MiddleName: | MOSES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PANOSSIAN | ||||||||
| OtherFirstName: | APRAHAM | ||||||||
| OtherMiddleName: | MOVSES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 S DOBSON RD BLDG A | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807866655 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 S DOBSON RD BLDG A | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807866655 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2007 | ||||||||
| LastUpdateDate: | 06/25/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A99283 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | ME101157 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 000217600 | 05 | FL | MEDICAID | 658249 | 05 | AZ | MEDICAID | 44704 | 01 | AZ | LICENSE | OTHER |