Healthcare Provider Details

I. General information

NPI: 1467257568
Provider Name (Legal Business Name): MARIAM KHALED GHANEM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 4TH ST
SAN FRANCISCO CA
94143-2351
US

IV. Provider business mailing address

7575 KIRBY DR APT 3404
HOUSTON TX
77030-4453
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1000
  • Fax:
Mailing address:
  • Phone: 936-524-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number95033634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: