Provider Demographics
NPI:1073138277
Name:KHEIREDDIN, ABRAHAM SAMIR (PA-C)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:SAMIR
Last Name:KHEIREDDIN
Suffix:
Gender:M
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 1:8346 MENARD AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-2658
Mailing Address - Country:US
Mailing Address - Phone:708-263-7750
Mailing Address - Fax:
Practice Address - Street 1:10330 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1971
Practice Address - Country:US
Practice Address - Phone:708-237-7200
Practice Address - Fax:708-237-7201
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-009053OtherSTATE LICENSE