Provider Demographics
NPI:1518366947
Name:ZAMANI, ATIQ (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ATIQ
Middle Name:
Last Name:ZAMANI
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:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:
Practice Address - Street 1:1312 W. ARCH HAVEN AVENUE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-676-4144
Practice Address - Fax:812-339-8344
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001706A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN090540071Medicare PIN