Provider Demographics
NPI:1013947381
Name:QURESHI, EBENEZER KHURAM (PA-C)
Entity Type:Individual
Prefix:
First Name:EBENEZER
Middle Name:KHURAM
Last Name:QURESHI
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 1:1507 N LITCHFIELD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-1201
Mailing Address - Country:US
Mailing Address - Phone:623-215-0040
Mailing Address - Fax:623-935-9602
Practice Address - Street 1:1507 N LITCHFIELD RD STE 200
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1201
Practice Address - Country:US
Practice Address - Phone:623-215-0040
Practice Address - Fax:623-935-9602
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58215363A00000X
AZ3253363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q63899Medicare UPIN
AZZ108055Medicare PIN
AZZ108056Medicare PIN