Healthcare Provider Details

I. General information

NPI: 1982207932
Provider Name (Legal Business Name): MIDWEST HEALTHCARE GROUPS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21410 136TH AVE N ,STE 105B
ROGERS MN
55374-4921
US

IV. Provider business mailing address

21410 136TH AVE STE 105B
ROGERS MN
55374-4921
US

V. Phone/Fax

Practice location:
  • Phone: 763-290-6622
  • Fax: 949-288-0273
Mailing address:
  • Phone: 763-290-6622
  • Fax: 949-288-0273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. AMMAR KHASHAN
Title or Position: CEO
Credential: PA-C
Phone: 651-829-4326