Provider Demographics
NPI:1649856733
Name:FAROZE, MOHAMMED REEZA (PA-C)
Entity type:Individual
Prefix:MR
First Name:MOHAMMED
Middle Name:REEZA
Last Name:FAROZE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2863
Mailing Address - Country:US
Mailing Address - Phone:212-385-3700
Mailing Address - Fax:
Practice Address - Street 1:4211 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2863
Practice Address - Country:US
Practice Address - Phone:212-385-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-20
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY026595363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program