Provider Demographics
NPI:1073931069
Name:IDREES, FIZZAH
Entity type:Individual
Prefix:MS
First Name:FIZZAH
Middle Name:
Last Name:IDREES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:FIZZAH
Other - Middle Name:
Other - Last Name:IDREES-IQBAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1279 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2583
Mailing Address - Country:US
Mailing Address - Phone:631-727-2100
Mailing Address - Fax:
Practice Address - Street 1:1279 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2583
Practice Address - Country:US
Practice Address - Phone:631-727-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant