=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932129707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRINA BAZAVAN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 GRANT AVE SUITE 150
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94945-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-899-9800
-----------------------------------------------------
Fax | 415-899-9805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 750 GRANT AVE SUITE 150
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94945-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-899-9800
-----------------------------------------------------
Fax | 415-899-9805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 8749
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------