Healthcare Provider Details

I. General information

NPI: 1770492662
Provider Name (Legal Business Name): GHOLAMREZA ATAOLLAHETABRIZI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19377 GERMAIN ST
PORTER RANCH CA
91326-2955
US

IV. Provider business mailing address

19377 GERMAIN ST
PORTER RANCH CA
91326-2955
US

V. Phone/Fax

Practice location:
  • Phone: 949-300-6713
  • Fax:
Mailing address:
  • Phone: 949-300-6713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95041250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: