Provider Demographics
NPI:1790120012
Name:AHSAN, SUNDUS (PA-C)
Entity Type:Individual
Prefix:
First Name:SUNDUS
Middle Name:
Last Name:AHSAN
Suffix:
Gender:F
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 1:6101 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2952
Mailing Address - Country:US
Mailing Address - Phone:847-581-6100
Mailing Address - Fax:
Practice Address - Street 1:6101 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2952
Practice Address - Country:US
Practice Address - Phone:847-581-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant