Provider Demographics
NPI:1730646696
Name:BAHRA, MAREN (PA)
Entity Type:Individual
Prefix:
First Name:MAREN
Middle Name:
Last Name:BAHRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24715 LITTLE MACK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24715 LITTLE MACK AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3207
Practice Address - Country:US
Practice Address - Phone:586-779-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5601009035363A00000X
MI5601008989TMP363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant