Provider Demographics
NPI:1215659081
Name:ISLAM, TAHIYA (PA-C)
Entity type:Individual
Prefix:
First Name:TAHIYA
Middle Name:
Last Name:ISLAM
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 1:13500 CHENAL PKWY APT 3023
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-5206
Mailing Address - Country:US
Mailing Address - Phone:870-540-6370
Mailing Address - Fax:
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:423-426-3918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant