Healthcare Provider Details

I. General information

NPI: 1093005233
Provider Name (Legal Business Name): ELAINE WEST HAJISAFARI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LOURDES ELAINE WEST

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 NW 12TH AVE
MIAMI FL
33136-1002
US

IV. Provider business mailing address

1611 NW 12TH AVE PO BOX 016960 (M851)
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-8644
  • Fax:
Mailing address:
  • Phone: 305-243-7688
  • Fax: 305-243-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9105870
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: