Provider Demographics
NPI:1649887001
Name:AZUCENA, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:AZUCENA
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 1:32100 TELEGRAPH RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2454
Mailing Address - Country:US
Mailing Address - Phone:248-712-4266
Mailing Address - Fax:
Practice Address - Street 1:32100 TELEGRAPH RD STE 205
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2454
Practice Address - Country:US
Practice Address - Phone:248-712-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2023-11-08
Deactivation Date:2023-11-03
Deactivation Code:
Reactivation Date:2023-11-07
Provider Licenses
StateLicense IDTaxonomies
156F00000X
MI5601012070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No156F00000XEye and Vision Services ProvidersTechnician/Technologist