Provider Demographics
NPI:1043258957
Name:BHATTI, MANSOOR IQBAL (PAC)
Entity type:Individual
Prefix:
First Name:MANSOOR
Middle Name:IQBAL
Last Name:BHATTI
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 MONROE ST
Mailing Address - Street 2:SUITE #209
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2921
Mailing Address - Country:US
Mailing Address - Phone:313-359-3800
Mailing Address - Fax:313-277-4100
Practice Address - Street 1:2040 MONROE ST
Practice Address - Street 2:SUITE #209
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2921
Practice Address - Country:US
Practice Address - Phone:313-359-3800
Practice Address - Fax:313-277-4100
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002334363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1032778OtherCERTIFICATION NUMBER
MA1032778OtherCERTIFICATION NUMBER