Provider Demographics
NPI:1336573146
Name:IJAZ, FAISAL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:FAISAL
Middle Name:
Last Name:IJAZ
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 GRIMES RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2406
Mailing Address - Country:US
Mailing Address - Phone:860-597-1331
Mailing Address - Fax:
Practice Address - Street 1:580 BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3579
Practice Address - Country:US
Practice Address - Phone:860-528-5068
Practice Address - Fax:860-528-2341
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily