Basic Information
| Provider Information | |||||||||
| NPI: | 1760070072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAZZY | ||||||||
| FirstName: | MOHAMMED | ||||||||
| MiddleName: | NADER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25639 FORD RD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481274817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132773293 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25639 FORD RD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481274817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132773293 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2021 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704304697 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 4704304697 | 01 | MI | NURSE PRACTITIONER SPECIALTY LICENSE | OTHER |