Healthcare Provider Details

I. General information

NPI: 1134500630
Provider Name (Legal Business Name): STEVE KHAVANDEGARAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W COMMERCIAL BLVD SUITE 5
FT LAUDERDALE FL
33309-3300
US

IV. Provider business mailing address

3601 W COMMERCIAL BLVD SUITE 5
FT LAUDERDALE FL
33309-3300
US

V. Phone/Fax

Practice location:
  • Phone: 954-703-2931
  • Fax: 954-585-9207
Mailing address:
  • Phone: 954-703-2931
  • Fax: 954-585-9207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9289405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: