1063758100 NPI number — REESHMA S MOHAMMED MSN, FNP-BC

Table of content: REESHMA S MOHAMMED MSN, FNP-BC (NPI 1063758100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063758100 NPI number — REESHMA S MOHAMMED MSN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOHAMMED
Provider First Name:
REESHMA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063758100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2940 E. BANNER GATEWAY DRIVE
Provider Second Line Business Mailing Address:
SUITE 450
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-258-3430
Provider Business Mailing Address Fax Number:
480-256-3682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3181 SW SAM JACKSON PARK RD # L586
Provider Second Line Business Practice Location Address:
DIVISION OF HEMATOLOGY & MEDICAL ONCOLOGY
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-8534
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  NP-13808 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP125593 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 201603125NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)