Healthcare Provider Details

I. General information

NPI: 1225664337
Provider Name (Legal Business Name): WAJIHA IMRAN MASOOD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 06/05/2022
Certification Date: 06/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 COMMERCE DR
ALGONQUIN IL
60102-5916
US

IV. Provider business mailing address

1465 COMMERCE DR
ALGONQUIN IL
60102-5916
US

V. Phone/Fax

Practice location:
  • Phone: 847-802-7090
  • Fax: 847-802-7095
Mailing address:
  • Phone: 847-802-7090
  • Fax: 847-802-7095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007876
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: