Provider Demographics
NPI:1598091134
Name:QAYYUM, NUSRAT (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NUSRAT
Middle Name:
Last Name:QAYYUM
Suffix:
Gender:F
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 1:4967 CROOKS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-1614
Practice Address - Street 1:4005 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-0001
Practice Address - Country:US
Practice Address - Phone:989-839-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-01
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant