MEDICARE: NEEMA KIANFAR MS, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1699412114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEEMA KIANFAR MS, ATC

Provider Business Mailing Address
First Line	:	4851 SAN JUAN AVE
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-4721
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4851 SAN JUAN AVE
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-4721
Country	:	US
Telephone Number	:	916-501-9508
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2022
Last Update Date	:	05/16/2022

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