Healthcare Provider Details

I. General information

NPI: 1205549789
Provider Name (Legal Business Name): AZITA BANANDARGAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3652 W SHIELDS AVE
FRESNO CA
93722
US

IV. Provider business mailing address

3652 W SHIELDS AVE
FRESNO CA
93722
US

V. Phone/Fax

Practice location:
  • Phone: 800-492-4227
  • Fax:
Mailing address:
  • Phone: 800-492-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95023261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: