Healthcare Provider Details

I. General information

NPI: 1801577234
Provider Name (Legal Business Name): NICOLE LAZAREV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 BUCKINGHAM WAY APT 203
SAN FRANCISCO CA
94132-1899
US

IV. Provider business mailing address

265 BUCKINGHAM WAY APT 203
SAN FRANCISCO CA
94132-1899
US

V. Phone/Fax

Practice location:
  • Phone: 415-260-7020
  • Fax:
Mailing address:
  • Phone: 415-260-7020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number63767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: