Provider Demographics
NPI:1396207346
Name:MIARI, ASSEM (PA)
Entity Type:Individual
Prefix:
First Name:ASSEM
Middle Name:
Last Name:MIARI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SW PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-3025
Mailing Address - Country:US
Mailing Address - Phone:515-864-1660
Mailing Address - Fax:
Practice Address - Street 1:8201 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007422363AS0400X
TXPA12716363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA12716OtherTMB
IL085007422OtherIDFPR