Healthcare Provider Details

I. General information

NPI: 1902303555
Provider Name (Legal Business Name): NABIHA NOMA AWAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S. GRAND BLVD. ROOM 2717
ST. LOUIS MO
63104-1004
US

IV. Provider business mailing address

1465 S. GRAND BLVD. ROOM 2717
ST. LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4070
  • Fax: 314-268-4019
Mailing address:
  • Phone: 314-268-4070
  • Fax: 314-268-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021014625
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: