Basic Information
| Provider Information | |||||||||
| NPI: | 1629541131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISMAIL | ||||||||
| FirstName: | IMAN | ||||||||
| MiddleName: | FAYAK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4691 ROLLING RIDGE RD | ||||||||
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| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483233343 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20280 MIDDLEBELT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481522002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489871270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2019 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601008934 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.