Provider Demographics
NPI:1336794429
Name:EISSA, MOUSA GOMAA
Entity Type:Individual
Prefix:
First Name:MOUSA
Middle Name:GOMAA
Last Name:EISSA
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 1:2 HURLEY PLZ STE 101
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5904
Mailing Address - Country:US
Mailing Address - Phone:810-262-6426
Mailing Address - Fax:
Practice Address - Street 1:2 HURLEY PLZ STE 101
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5904
Practice Address - Country:US
Practice Address - Phone:810-262-6426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351045153390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program