Provider Demographics
NPI:1730388497
Name:MOUAWAD, NICOLAS JANO
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:JANO
Last Name:MOUAWAD
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 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:2431 S M 30
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9312
Practice Address - Country:US
Practice Address - Phone:989-343-3264
Practice Address - Fax:989-343-3202
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090259390200000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program