Healthcare Provider Details

I. General information

NPI: 1508032335
Provider Name (Legal Business Name): NISSA MARIE KEYASHIAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S WINCHESTER BLVD STE A101
SAN JOSE CA
95128-3914
US

IV. Provider business mailing address

1101 S WINCHESTER BLVD STE A101
SAN JOSE CA
95128-3914
US

V. Phone/Fax

Practice location:
  • Phone: 408-854-8180
  • Fax: 408-484-6377
Mailing address:
  • Phone: 408-854-8180
  • Fax: 408-484-6377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA113773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: