Provider Demographics
NPI:1154185387
Name:ANSARI, MOHAMMED ABDUL MANNAN (PA-C)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:ABDUL MANNAN
Last Name:ANSARI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:8127 MERRILLVILLE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6306
Mailing Address - Country:US
Mailing Address - Phone:219-208-6218
Mailing Address - Fax:
Practice Address - Street 1:7350 W COLLEGE DR STE 103
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1187
Practice Address - Country:US
Practice Address - Phone:708-694-9876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085.010291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant