Provider Demographics
NPI:1336783562
Name:BAZILE, ANICK (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:ANICK
Middle Name:
Last Name:BAZILE
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-6913
Mailing Address - Country:US
Mailing Address - Phone:650-589-6500
Mailing Address - Fax:
Practice Address - Street 1:192 BEACON ST
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-6913
Practice Address - Country:US
Practice Address - Phone:650-589-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2020-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112564363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical