Provider Demographics
NPI:1760164735
Name:BAZAN, MARILYN (APRN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BAZAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 W 72ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5222
Mailing Address - Country:US
Mailing Address - Phone:305-213-0007
Mailing Address - Fax:
Practice Address - Street 1:11225 MIRAMAR PKWY
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-1964
Practice Address - Country:US
Practice Address - Phone:754-202-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11016987208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty