Provider Demographics
NPI:1104279512
Name:ALI, NOUR
Entity type:Individual
Prefix:
First Name:NOUR
Middle Name:
Last Name:ALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LAKE VILLAGE BLVD
Mailing Address - Street 2:APT 103
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19145 ALLEN RD
Practice Address - Street 2:#107
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-6812
Practice Address - Country:US
Practice Address - Phone:734-486-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical