Healthcare Provider Details

I. General information

NPI: 1417757550
Provider Name (Legal Business Name): BAIAN AHMAD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAKE ST STE LL54
OAK PARK IL
60301-1099
US

IV. Provider business mailing address

1210 S INDIANA AVE APT 5406
CHICAGO IL
60605-3036
US

V. Phone/Fax

Practice location:
  • Phone: 404-631-6156
  • Fax:
Mailing address:
  • Phone: 312-783-7384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number66165
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: