Healthcare Provider Details

I. General information

NPI: 1316971880
Provider Name (Legal Business Name): AFTAB A AWAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

140 S 40TH ST
OMAHA NE
68131-3045
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2730
  • Fax: 360-414-2739
Mailing address:
  • Phone: 402-637-3632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30343
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036-143847
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberMD61185856
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD61185856
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD61185856
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101280393
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: