Healthcare Provider Details

I. General information

NPI: 1952228421
Provider Name (Legal Business Name): MRS. ATHAR GHASSEMI BOLOURCHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 W MILLER ST
ORLANDO FL
32806-2031
US

IV. Provider business mailing address

2240 PALM VISTA DR
APOPKA FL
32712-2445
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-9792
  • Fax:
Mailing address:
  • Phone: 407-547-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0121X
TaxonomyPlastic Surgery Registered Nurse
License Number721058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: