Provider Demographics
NPI:1194425082
Name:AHMADZAI, WALI M
Entity type:Individual
Prefix:
First Name:WALI
Middle Name:M
Last Name:AHMADZAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 UPTOWN RD APT 9
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1604
Mailing Address - Country:US
Mailing Address - Phone:607-280-9684
Mailing Address - Fax:
Practice Address - Street 1:101 UPTOWN RD APT 9
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1604
Practice Address - Country:US
Practice Address - Phone:607-280-9684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant