Healthcare Provider Details

I. General information

NPI: 1982900718
Provider Name (Legal Business Name): MIRA B AIDASANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRA B AIDASANI-DIWATA

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 MORSE AVE
SACRAMENTO CA
95825-2135
US

IV. Provider business mailing address

2016 MORSE AVE
SACRAMENTO CA
95825-2135
US

V. Phone/Fax

Practice location:
  • Phone: 916-973-5000
  • Fax: 877-738-4262
Mailing address:
  • Phone: 916-973-5000
  • Fax: 877-738-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20469
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: