Provider Demographics
NPI:1326664194
Name:HUMAISAN, IBRAHIM
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:HUMAISAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4025
Mailing Address - Country:US
Mailing Address - Phone:313-655-4809
Mailing Address - Fax:
Practice Address - Street 1:10140 VERNOR HWY
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1515
Practice Address - Country:US
Practice Address - Phone:313-438-6059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant