Provider Demographics
NPI:1982978094
Name:BAZAN, NOE (OTR)
Entity Type:Individual
Prefix:
First Name:NOE
Middle Name:
Last Name:BAZAN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 E MAIN AVE STE H&I
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:TX
Mailing Address - Zip Code:78573-0907
Mailing Address - Country:US
Mailing Address - Phone:956-638-6162
Mailing Address - Fax:
Practice Address - Street 1:3012 E MAIN AVE STE H&I
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:TX
Practice Address - Zip Code:78573-0907
Practice Address - Country:US
Practice Address - Phone:956-638-6162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114651225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173943501Medicaid