Basic Information
| Provider Information | |||||||||
| NPI: | 1396207346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIARI | ||||||||
| FirstName: | ASSEM | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 SW PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | ANKENY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500233025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158641660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8201 E RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159717000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2019 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085007422 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA12716 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA12716 | 01 | TX | TMB | OTHER | 085007422 | 01 | IL | IDFPR | OTHER |