Provider Demographics
NPI:1396400925
Name:BAZYAN, NAREK GAGIK (PA-C)
Entity Type:Individual
Prefix:
First Name:NAREK
Middle Name:GAGIK
Last Name:BAZYAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4562 WINKLER AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-7021
Mailing Address - Country:US
Mailing Address - Phone:347-284-8802
Mailing Address - Fax:
Practice Address - Street 1:17 E OLD COUNTRY RD UNIT 305
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4270
Practice Address - Country:US
Practice Address - Phone:917-310-3371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027853363A00000X
FL9114992363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty