Basic Information
| Provider Information | |||||||||
| NPI: | 1215490891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IFTIKHAR | ||||||||
| FirstName: | MARYAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38 BOLDUC CT | ||||||||
| Address2: | |||||||||
| City: | WOLCOTT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067163146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035785157 | ||||||||
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| Practice Location | |||||||||
| Address1: | 672 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061093053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609673600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4424 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.