Provider Demographics
NPI:1659902518
Name:BASAJ, LAWRENCE J
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:BASAJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38550 MEADOWDALE ST APT 7
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3533
Mailing Address - Country:US
Mailing Address - Phone:586-855-3551
Mailing Address - Fax:
Practice Address - Street 1:38550 MEADOWDALE ST APT 7
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-3533
Practice Address - Country:US
Practice Address - Phone:586-855-3551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI484564146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic