Provider Demographics
NPI:1396024006
Name:ALAQZAM, TASNEEM SALEH
Entity Type:Individual
Prefix:
First Name:TASNEEM
Middle Name:SALEH
Last Name:ALAQZAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TASNEEM
Other - Middle Name:SALEH
Other - Last Name:ALAQZAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:KU WICHITA GENERAL PEDIATRIC 620 N CARRIAGE PKWY
Mailing Address - Street 2:620 N CARRIAGE PARKWAY
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4910
Practice Address - Country:US
Practice Address - Phone:316-962-2000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-40623207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1396024006Medicaid