Provider Demographics
NPI:1619725645
Name:EL SIDDIG, ABDULBAGE
Entity type:Individual
Prefix:
First Name:ABDULBAGE
Middle Name:
Last Name:EL SIDDIG
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 1:1222 E MALCOLM X ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1618
Mailing Address - Country:US
Mailing Address - Phone:517-505-5162
Mailing Address - Fax:
Practice Address - Street 1:1000 WILLOW CREEK RD STE F
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1645
Practice Address - Country:US
Practice Address - Phone:928-227-0912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR81022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant