Healthcare Provider Details

I. General information

NPI: 1457100679
Provider Name (Legal Business Name): FADI QAQISH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 E STILL CIR
MESA AZ
85206-3618
US

IV. Provider business mailing address

12316 ROSE LN
OMAHA NE
68154-1467
US

V. Phone/Fax

Practice location:
  • Phone: 480-248-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: