1265459184 NPI number — AZAR S BASTANFAR CERTIFIED NURSE PRAC

Table of content: AZAR S BASTANFAR CERTIFIED NURSE PRAC (NPI 1265459184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265459184 NPI number — AZAR S BASTANFAR CERTIFIED NURSE PRAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASTANFAR
Provider First Name:
AZAR
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CERTIFIED NURSE PRAC
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:
1265459184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FILE #54433
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-4433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-784-5888
Provider Business Mailing Address Fax Number:
760-414-3713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9850 GENESEE AVE
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-453-0753
Provider Business Practice Location Address Fax Number:
760-414-3713
Provider Enumeration Date:
07/16/2006

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: 363LX0001X , with the licence number:  538431 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 9526 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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