Healthcare Provider Details

I. General information

NPI: 1134650831
Provider Name (Legal Business Name): RYAN N. QASAWA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 KIRTS BLVD STE 700
TROY MI
48084-4853
US

IV. Provider business mailing address

1080 KIRTS BLVD STE 700
TROY MI
48084-4853
US

V. Phone/Fax

Practice location:
  • Phone: 248-362-2300
  • Fax: 248-362-5272
Mailing address:
  • Phone: 248-362-2300
  • Fax: 248-362-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number5101027584
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: