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General NPI Number Information
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NPI Number | 1386040046
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Entity Type | Individual
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Provider Name | MAHAM MUSHTAQ PA
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Gender | Female
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Dates
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Enumeration Date | 11/07/2014
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Last Update Date | 10/04/2022
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Provider Practice Location Address
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Address Line | 16258 FORT ST
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City | SOUTHGATE
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State | MI
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Zip | 48195-1401
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Country | US
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Telephone | 734-250-9062
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Fax |
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Provider Business Mailing Address
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Address Line | 1 FORD PL STE 3A
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City | DETROIT
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State | MI
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Zip | 48202-3450
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Country | US
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Telephone | 313-874-4806
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 10001768A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601008981
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License Number State | MI
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