Provider Demographics
NPI:1568702496
Name:SUFYAN, BASHEER (PA)
Entity Type:Individual
Prefix:
First Name:BASHEER
Middle Name:
Last Name:SUFYAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 NW 43RD ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-4565
Mailing Address - Country:US
Mailing Address - Phone:517-706-9777
Mailing Address - Fax:
Practice Address - Street 1:3925 NW 43RD ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-4565
Practice Address - Country:US
Practice Address - Phone:352-371-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006608363A00000X
CT5508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant