Provider Demographics
NPI:1821495276
Name:BOUZOU, LOUBABATOU (PA)
Entity Type:Individual
Prefix:
First Name:LOUBABATOU
Middle Name:
Last Name:BOUZOU
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 1:920 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069-3839
Mailing Address - Country:US
Mailing Address - Phone:847-866-7846
Mailing Address - Fax:866-954-5815
Practice Address - Street 1:920 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:866-954-5815
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005045363A00000X
MEPA1493363AS0400X
NDPAC0666363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant