Provider Demographics
NPI:1124656350
Name:ABDUL-WAHID, ISMAIL (PA-C)
Entity type:Individual
Prefix:MR
First Name:ISMAIL
Middle Name:
Last Name:ABDUL-WAHID
Suffix:
Gender:M
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 1:724 E HENRY ST
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-2132
Mailing Address - Country:US
Mailing Address - Phone:908-967-3661
Mailing Address - Fax:718-245-4689
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-4687
Practice Address - Fax:718-245-4689
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ363A00000X
390200000X
NY363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program