Provider Demographics
NPI:1326421967
Name:YASIN, GHENOI
Entity Type:Individual
Prefix:
First Name:GHENOI
Middle Name:
Last Name:YASIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GHENOI
Other - Middle Name:
Other - Last Name:NASSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:106 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1314
Mailing Address - Country:US
Mailing Address - Phone:313-645-1775
Mailing Address - Fax:
Practice Address - Street 1:5728 SCHAEFER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2298
Practice Address - Country:US
Practice Address - Phone:313-624-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant