Healthcare Provider Details

I. General information

NPI: 1457660466
Provider Name (Legal Business Name): MR. NOMAN ALAM BASHIR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2010
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date: 07/21/2026
Reactivation Date: 08/12/2026

III. Provider practice location address

1106 TALON TRCE
LAWRENCEVILLE GA
30043-7105
US

IV. Provider business mailing address

15739 SW 102ND ST
MIAMI FL
33196-5420
US

V. Phone/Fax

Practice location:
  • Phone: 305-297-9510
  • Fax:
Mailing address:
  • Phone: 305-297-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1095084
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number02871301
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: