Healthcare Provider Details

I. General information

NPI: 1417563404
Provider Name (Legal Business Name): HUNNAAN MOHAMMED KHAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W 19TH ST
CHICAGO IL
60623-3501
US

IV. Provider business mailing address

3909 N WESTERN AVE
CHICAGO IL
60618-3741
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-1000
  • Fax:
Mailing address:
  • Phone: 773-739-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14271
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010251
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: