Basic Information
| Provider Information | |||||||||
| NPI: | 1871510883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDUL-WADUD | ||||||||
| FirstName: | BASHIR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 391 | ||||||||
| Address2: | INNOVATIVE PHYSICIAN SERVICES, LLC | ||||||||
| City: | WILBRAHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010950391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085950531 | ||||||||
| FaxNumber: | 5088295367 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 COOPER ST | ||||||||
| Address2: | INNOVATIVE PHYSICIAN SERVICES, LLC | ||||||||
| City: | AGAWAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010012149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137868000 | ||||||||
| FaxNumber: | 4137869788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 12/11/2015 | ||||||||
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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 | 363AM0700X | 1876 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | MA057997 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.