Provider Demographics
NPI:1083843668
Name:NISAR, AMINA
Entity Type:Individual
Prefix:
First Name:AMINA
Middle Name:
Last Name:NISAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 WILLOW COVE BLVD
Mailing Address - Street 2:APT G9
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-3263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-05
Last Update Date:2009-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine