Provider Demographics
NPI:1669490694
Name:MIRZA M ASHRAF & MULAZIM H KHAN
Entity type:Organization
Organization Name:MIRZA M ASHRAF & MULAZIM H KHAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:315-493-1450
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:NY
Mailing Address - Zip Code:13673
Mailing Address - Country:US
Mailing Address - Phone:315-642-0026
Mailing Address - Fax:314-642-1028
Practice Address - Street 1:32787 US RT 11
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:NY
Practice Address - Zip Code:13673
Practice Address - Country:US
Practice Address - Phone:315-642-0026
Practice Address - Fax:315-642-1028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003616-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02568298Medicaid
NY01188238Medicaid
NY119064OtherMVP
NY02568298Medicaid
NY119064OtherMVP
NY=========OtherBCBS