Provider Demographics
NPI:1912759630
Name:KOTHAWALA, FARHEEN (PA-C)
Entity type:Individual
Prefix:
First Name:FARHEEN
Middle Name:
Last Name:KOTHAWALA
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:FARHEEN
Other - Middle Name:JAVEED
Other - Last Name:SHETHWALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2650 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-982-3172
Mailing Address - Fax:
Practice Address - Street 1:501 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2802
Practice Address - Country:US
Practice Address - Phone:847-504-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2025-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085010723363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical