Provider Demographics
NPI:1427567569
Name:MANSOUR, SALAH ELDEIN (PA-C)
Entity Type:Individual
Prefix:
First Name:SALAH
Middle Name:ELDEIN
Last Name:MANSOUR
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 1:26942 ROCHELLE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3672
Mailing Address - Country:US
Mailing Address - Phone:313-213-9433
Mailing Address - Fax:
Practice Address - Street 1:2176 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2405
Practice Address - Country:US
Practice Address - Phone:313-388-1666
Practice Address - Fax:313-388-6961
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant