Provider Demographics
NPI:1346645108
Name:MORTADA, MAYA
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:MORTADA
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 1:920 N MILDRED ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1733
Mailing Address - Country:US
Mailing Address - Phone:313-404-9960
Mailing Address - Fax:
Practice Address - Street 1:1 FORD PL
Practice Address - Street 2:4B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3450
Practice Address - Country:US
Practice Address - Phone:313-404-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277486363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics