Provider Demographics
NPI:1407320559
Name:MIRZA, AHMED IHSAN (FNP-C)
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:IHSAN
Last Name:MIRZA
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19100 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1156
Mailing Address - Country:US
Mailing Address - Phone:313-763-0309
Mailing Address - Fax:313-771-9947
Practice Address - Street 1:19100 GODDARD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1156
Practice Address - Country:US
Practice Address - Phone:313-763-0309
Practice Address - Fax:313-771-9947
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2023-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH079537-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily