Healthcare Provider Details

I. General information

NPI: 1770045825
Provider Name (Legal Business Name): HIRBOD BEHBAHANINIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5133 N CENTRAL AVE STE 206
PHOENIX AZ
85012-1438
US

IV. Provider business mailing address

PO BOX 910221
DALLAS TX
75391-5999
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-0608
  • Fax: 602-234-0417
Mailing address:
  • Phone: 520-519-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7906
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: