Healthcare Provider Details

I. General information

NPI: 1710856323
Provider Name (Legal Business Name): KHIZAR AHMED SIDDIQUI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 MERRICK RD STE 300
LYNBROOK NY
11563-2526
US

IV. Provider business mailing address

565 HEMPSTEAD AVE
WEST HEMPSTEAD NY
11552-2907
US

V. Phone/Fax

Practice location:
  • Phone: 516-256-2017
  • Fax:
Mailing address:
  • Phone: 646-436-8291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: