Provider Demographics
NPI:1053592238
Name:DABAJA, IBRAHIM HUSSEIN (PA)
Entity type:Individual
Prefix:MR
First Name:IBRAHIM
Middle Name:HUSSEIN
Last Name:DABAJA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-2306
Mailing Address - Country:US
Mailing Address - Phone:734-299-0712
Mailing Address - Fax:734-574-6060
Practice Address - Street 1:1768 FORD AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-2306
Practice Address - Country:US
Practice Address - Phone:313-377-5758
Practice Address - Fax:734-574-6060
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2022-12-19
Deactivation Date:2021-04-23
Deactivation Code:
Reactivation Date:2021-05-20
Provider Licenses
StateLicense IDTaxonomies
MI5601004858363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1158216100OtherBCBS
MI1158216100OtherBCBS