Provider Demographics
NPI:1174067425
Name:BAZIN, DIMITRI (PA)
Entity type:Individual
Prefix:
First Name:DIMITRI
Middle Name:
Last Name:BAZIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3424
Mailing Address - Country:US
Mailing Address - Phone:212-470-1000
Mailing Address - Fax:
Practice Address - Street 1:3418 BROADWAY OFC 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-7408
Practice Address - Country:US
Practice Address - Phone:212-283-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP04485363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical