Healthcare Provider Details

I. General information

NPI: 1134115462
Provider Name (Legal Business Name): ALI ASGHER KHANSHAB RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PALISADES DR
ALBANY NY
12205-1438
US

IV. Provider business mailing address

4 ATRIUM DR SUITE 100, ATTN: TAMMY M. BUTTON
ALBANY NY
12205-1441
US

V. Phone/Fax

Practice location:
  • Phone: 518-458-2000
  • Fax: 518-458-1524
Mailing address:
  • Phone: 518-435-2740
  • Fax: 518-458-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number010790
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: