MEDICARE: WASIYA FAROOQUI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	085.008574	IL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1619593464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WASIYA FAROOQUI

Provider Business Mailing Address
First Line	:	2335 W FULLERTON AVE STE B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2335 W FULLERTON AVE STE B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3225
Country	:	US
Telephone Number	:	815-603-5852
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2020
Last Update Date	:	11/03/2023

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Directions to “ WASIYA FAROOQUI ” Practice Location

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