Provider Demographics
NPI:1316971880
Name:AWAN, AFTAB A (MD)
Entity type:Individual
Prefix:
First Name:AFTAB
Middle Name:A
Last Name:AWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S 40TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-3045
Mailing Address - Country:US
Mailing Address - Phone:402-637-3632
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-414-2730
Practice Address - Fax:360-414-2739
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30343207P00000X
IL036-1438472084N0400X
WAMD61185856103G00000X, 208VP0014X, 2084N0400X
VA01012803932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG01226Medicare UPIN