Provider Demographics
NPI:1518364538
Name:JAFFERY, TAHIR (PA)
Entity Type:Individual
Prefix:
First Name:TAHIR
Middle Name:
Last Name:JAFFERY
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-904-7000
Mailing Address - Fax:
Practice Address - Street 1:963 N 129TH INFANTRY DR
Practice Address - Street 2:100
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3104
Practice Address - Country:US
Practice Address - Phone:815-741-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant