Provider Demographics
NPI:1275995425
Name:MOUSSA PACHA, HOMAM
Entity type:Individual
Prefix:
First Name:HOMAM
Middle Name:
Last Name:MOUSSA PACHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3539
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-3539
Mailing Address - Country:US
Mailing Address - Phone:928-453-2727
Mailing Address - Fax:928-453-2828
Practice Address - Street 1:4201 SAINT ANTOINE ST # 9C
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-5146
Practice Address - Fax:313-745-5146
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-27
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ67883207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ129869Medicaid