Healthcare Provider Details

I. General information

NPI: 1437930302
Provider Name (Legal Business Name): NADIR BAZIZ APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SAINT JOSEPH DR
BLOOMINGTON IL
61701-3636
US

IV. Provider business mailing address

2015 WINCHESTER DR
CHAMPAIGN IL
61821-6314
US

V. Phone/Fax

Practice location:
  • Phone: 217-819-2094
  • Fax:
Mailing address:
  • Phone: 217-819-2094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.027982
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.427787
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: