Healthcare Provider Details

I. General information

NPI: 1245189190
Provider Name (Legal Business Name): MAVIE CLINIC PROFESSIONAL NURSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 PORTRAIT LN
PATTERSON CA
95363-8341
US

IV. Provider business mailing address

109 PORTRAIT LN
PATTERSON CA
95363-8341
US

V. Phone/Fax

Practice location:
  • Phone: 209-806-4841
  • Fax: 209-290-3320
Mailing address:
  • Phone: 209-806-4841
  • Fax: 209-290-3320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MUKHTAR KOHISTANI
Title or Position: PRESIDENT
Credential: FNP-C
Phone: 209-806-4841