Healthcare Provider Details

I. General information

NPI: 1679974927
Provider Name (Legal Business Name): MINA VAFAEEZADEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

206 PARK LAKE CIR APT C
WALNUT CREEK CA
94598-5220
US

V. Phone/Fax

Practice location:
  • Phone: 425-241-4738
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: