Provider Demographics
NPI:1760070072
Name:BAZZY, MOHAMMED NADER
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:NADER
Last Name:BAZZY
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 1:25639 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-4817
Mailing Address - Country:US
Mailing Address - Phone:313-277-3293
Mailing Address - Fax:
Practice Address - Street 1:25639 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-4817
Practice Address - Country:US
Practice Address - Phone:313-277-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704304697OtherNURSE PRACTITIONER SPECIALTY LICENSE