Provider Demographics
NPI:1710915921
Name:ASLAM, MOHAMAD (CRNA)
Entity Type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:
Last Name:ASLAM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2133
Mailing Address - Country:US
Mailing Address - Phone:502-583-0909
Mailing Address - Fax:502-583-0913
Practice Address - Street 1:332 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2130
Practice Address - Country:US
Practice Address - Phone:502-583-0909
Practice Address - Fax:502-583-0913
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY107A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74310251Medicaid
KY0516818Medicare PIN