Provider Demographics
NPI:1457074932
Name:NAWAZ, FAHAD (PTA)
Entity Type:Individual
Prefix:MR
First Name:FAHAD
Middle Name:
Last Name:NAWAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6419C 186TH LN APT 1C
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3622
Mailing Address - Country:US
Mailing Address - Phone:212-518-4319
Mailing Address - Fax:
Practice Address - Street 1:2124 30TH AVE STE C1
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3491
Practice Address - Country:US
Practice Address - Phone:718-545-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011206225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant