Healthcare Provider Details

I. General information

NPI: 1467143321
Provider Name (Legal Business Name): KIRAN WASIQ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

465 W PUTNAM AVE
PORTERVILLE CA
93257-3320
US

V. Phone/Fax

Practice location:
  • Phone: 260-672-6620
  • Fax: 260-672-6639
Mailing address:
  • Phone: 559-788-6156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01099068A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: