Healthcare Provider Details

I. General information

NPI: 1376324103
Provider Name (Legal Business Name): ADHAM GHAZAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/09/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 SOQUEL AVE
SANTA CRUZ CA
95062-1402
US

IV. Provider business mailing address

3402 WYOMING BLVD NE BLDG 340206
ALBUQUERQUE NM
87111-4400
US

V. Phone/Fax

Practice location:
  • Phone: 469-927-7668
  • Fax:
Mailing address:
  • Phone: 469-927-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95352338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: