Healthcare Provider Details

I. General information

NPI: 1740128958
Provider Name (Legal Business Name): MOHAMMAD WASEF SALOUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 CITY BLVD W APT 304
ORANGE CA
92868-7910
US

IV. Provider business mailing address

180 CITY BLVD W APT 304
ORANGE CA
92868-7910
US

V. Phone/Fax

Practice location:
  • Phone: 657-282-1685
  • Fax:
Mailing address:
  • Phone: 657-282-1685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number54778
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: