Provider Demographics
NPI:1619386471
Name:MODI-MASOOD, SABENA JUZER (PA-C)
Entity Type:Individual
Prefix:
First Name:SABENA
Middle Name:JUZER
Last Name:MODI-MASOOD
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 1:1650 RAMBLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7396
Mailing Address - Country:US
Mailing Address - Phone:517-332-1200
Mailing Address - Fax:517-351-7122
Practice Address - Street 1:102 PAUL MELLON CT SUITE 102
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2788
Practice Address - Country:US
Practice Address - Phone:301-645-7414
Practice Address - Fax:301-645-7997
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005435363AM0700X
MI5601006961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical