Healthcare Provider Details

I. General information

NPI: 1417423401
Provider Name (Legal Business Name): AIDA NASIRISHARGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 V ST # 3500
SACRAMENTO CA
95817-1460
US

IV. Provider business mailing address

4150 V ST # 3500
SACRAMENTO CA
95817-1460
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-3759
  • Fax:
Mailing address:
  • Phone: 916-734-3759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA197297
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number18-67198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: