Healthcare Provider Details

I. General information

NPI: 1396259172
Provider Name (Legal Business Name): MASOUD NADI FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 70TH ST
LA MESA CA
91942-0701
US

IV. Provider business mailing address

4535 70TH ST
LA MESA CA
91942-0701
US

V. Phone/Fax

Practice location:
  • Phone: 619-609-9294
  • Fax: 619-720-2112
Mailing address:
  • Phone: 619-609-9294
  • Fax: 619-720-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: