Provider Demographics
NPI:1912169343
Name:HUBALLAH, AMIN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMIN
Middle Name:
Last Name:HUBALLAH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7526 WYOMING ST
Mailing Address - Street 2:SUITE #2
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1690
Mailing Address - Country:US
Mailing Address - Phone:313-834-4444
Mailing Address - Fax:
Practice Address - Street 1:7526 WYOMING ST
Practice Address - Street 2:SUITE #2
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1690
Practice Address - Country:US
Practice Address - Phone:313-834-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005284363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical