Healthcare Provider Details

I. General information

NPI: 1235679366
Provider Name (Legal Business Name): FAHIM UZZAMAN KHAN CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SOUTH AVE
LA CROSSE WI
54601-5467
US

IV. Provider business mailing address

1911 MILLER ST
LA CROSSE WI
54601-8505
US

V. Phone/Fax

Practice location:
  • Phone: 608-775-4010
  • Fax: 608-775-6723
Mailing address:
  • Phone: 608-775-4010
  • Fax: 608-775-6723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO02454
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO02454
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: