Basic Information
| Provider Information | |||||||||
| NPI: | 1770503377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANYZESKI | ||||||||
| FirstName: | KHANH | ||||||||
| MiddleName: | KIM | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241400 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Practice Location | |||||||||
| Address1: | 19910 S TAMIAMI TRL STE C | ||||||||
| Address2: | |||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339284140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394986912 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | J6722 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207Q00000X | OS 9865 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 121318305 | 05 | TX | MEDICAID | 277699500 | 05 | FL | MEDICAID |