Provider Demographics
NPI:1528473196
Name:FAYYAZ, IMRAN (PTA)
Entity type:Individual
Prefix:
First Name:IMRAN
Middle Name:
Last Name:FAYYAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39502 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-5807
Mailing Address - Country:US
Mailing Address - Phone:586-524-1994
Mailing Address - Fax:888-422-9893
Practice Address - Street 1:39502 AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-5807
Practice Address - Country:US
Practice Address - Phone:586-524-1994
Practice Address - Fax:888-422-9893
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000213225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant