Healthcare Provider Details

I. General information

NPI: 1386350775
Provider Name (Legal Business Name): ANTHONY MORADIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: QUESADA ANTHONY

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

10508 SUNLAND BLVD UNIT 4
SUNLAND CA
91040-1941
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-0425
  • Fax:
Mailing address:
  • Phone: 818-640-7513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95023929
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95023929
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number95217062
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95217062
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: