Healthcare Provider Details

I. General information

NPI: 1134010804
Provider Name (Legal Business Name): ABDIRAHMAN ALI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5285 LEWISTON RD
LEWISTON NY
14092-1942
US

IV. Provider business mailing address

PO BOX 7411009
CHICAGO IL
60674-3009
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax: 312-635-0050
Mailing address:
  • Phone: 872-231-3162
  • Fax: 312-635-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number034075
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: