Healthcare Provider Details

I. General information

NPI: 1275995425
Provider Name (Legal Business Name): HOMAM MOUSSA PACHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST # 9C
DETROIT MI
48201-2153
US

IV. Provider business mailing address

PO BOX 3539
LAKE HAVASU CITY AZ
86405-3539
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5146
  • Fax: 313-745-5146
Mailing address:
  • Phone: 928-453-2727
  • Fax: 928-453-2828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number67883
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number67883
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: