Provider Demographics
NPI:1619568805
Name:BAZZI, MALAK (PA)
Entity Type:Individual
Prefix:
First Name:MALAK
Middle Name:
Last Name:BAZZI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6401 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6401 MILLER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2363
Practice Address - Country:US
Practice Address - Phone:313-846-8800
Practice Address - Fax:313-846-0884
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601010130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant