Provider Demographics
NPI:1003495045
Name:GHATAN, PEIMAN
Entity type:Individual
Prefix:
First Name:PEIMAN
Middle Name:
Last Name:GHATAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MIDDLE NECK RD APT 2M
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1160
Mailing Address - Country:US
Mailing Address - Phone:410-458-6666
Mailing Address - Fax:
Practice Address - Street 1:260 MIDDLE NECK RD APT 2M
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1160
Practice Address - Country:US
Practice Address - Phone:410-458-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026513207QA0505X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine