Provider Demographics
NPI:1679612212
Name:HAN, AENA D (MD)
Entity type:Individual
Prefix:
First Name:AENA
Middle Name:D
Last Name:HAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AENA
Other - Middle Name:D
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1855 W REDLANDS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-3145
Mailing Address - Country:US
Mailing Address - Phone:909-890-0407
Mailing Address - Fax:909-890-0575
Practice Address - Street 1:1505 W 17TH ST STE 1
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1202
Practice Address - Country:US
Practice Address - Phone:909-887-6494
Practice Address - Fax:909-887-6043
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17791208000000X
TN52866208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01972509Medicaid
MS302I378186Medicare PIN
MS302I377703Medicare PIN