Healthcare Provider Details

I. General information

NPI: 1942692587
Provider Name (Legal Business Name): ALIREZA HAZRATI CRFNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 THOMAS JOHNSON DR
FREDERICK MD
21702-4501
US

IV. Provider business mailing address

74 THOMAS JOHNSON DR
FREDERICK MD
21702-4501
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-9033
  • Fax: 301-694-6204
Mailing address:
  • Phone: 301-694-9033
  • Fax: 301-694-6204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN0000180274
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC001852
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: