MEDICARE: AHMED FAZAL-UR-REHMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1376395822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AHMED FAZAL-UR-REHMAN

Provider Business Mailing Address
First Line	:	104 MERIDIAN AVE
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-7231
Country	:	US
Telephone Number	:	337-254-8508
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 MERIDIAN AVE
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-7231
Country	:	US
Telephone Number	:	337-254-8508
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2024
Last Update Date	:	04/05/2024

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