Provider Demographics
NPI:1689031445
Name:BASSIOUNI, MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BASSIOUNI
Suffix:
Gender:F
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 1:4366 PEARSON PKWY
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3572
Mailing Address - Country:US
Mailing Address - Phone:419-704-9478
Mailing Address - Fax:
Practice Address - Street 1:4366 PEARSON PKWY
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3572
Practice Address - Country:US
Practice Address - Phone:419-704-9478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2024-06-14
Deactivation Date:2023-07-11
Deactivation Code:
Reactivation Date:2024-06-10
Provider Licenses
StateLicense IDTaxonomies
OH50.002160RX363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0254822Medicaid