Healthcare Provider Details

I. General information

NPI: 1508043621
Provider Name (Legal Business Name): IFTIKHAR AHMAD MIAN PHYSICIANS ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270-05 76TH AVE NS LIJ HOSPITAL HEALTH SYSTEM
NEW HYDE PARK NY
11040
US

IV. Provider business mailing address

175 COMMUNITY DRIVE NS LIJ HEALTH SYSTEM
G NECK NY
11021
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7270
  • Fax: 718-470-0827
Mailing address:
  • Phone: 516-465-1900
  • Fax: 516-465-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003554
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: