Provider Demographics
NPI:1093359150
Name:FAIZ, FAZILLAH (PA-C)
Entity type:Individual
Prefix:
First Name:FAZILLAH
Middle Name:
Last Name:FAIZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 N ILLINOIS LN
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1969
Mailing Address - Country:US
Mailing Address - Phone:618-257-6380
Mailing Address - Fax:
Practice Address - Street 1:4000 N ILLINOIS LN
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1969
Practice Address - Country:US
Practice Address - Phone:618-257-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020028648363A00000X
IL085009213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant