Healthcare Provider Details

I. General information

NPI: 1396207346
Provider Name (Legal Business Name): ASSEM MIARI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 E RIVERSIDE BLVD
ROCKFORD IL
61114-2300
US

IV. Provider business mailing address

202 SW PLEASANT ST
ANKENY IA
50023-3025
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-7000
  • Fax:
Mailing address:
  • Phone: 515-864-1660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085007422
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12716
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: