Provider Demographics
NPI:1205379633
Name:MAKHZOUM, NOUR
Entity Type:Individual
Prefix:
First Name:NOUR
Middle Name:
Last Name:MAKHZOUM
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 1:14671 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-3300
Mailing Address - Country:US
Mailing Address - Phone:313-948-3030
Mailing Address - Fax:
Practice Address - Street 1:14671 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-3300
Practice Address - Country:US
Practice Address - Phone:313-948-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-03
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical