MEDICARE: SOUDEH KHAYAM-BASHI NP

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	363LA2100X	Acute Care Nurse Practitioner	95057258	CA

General Provider Information

NPI Number	:	1740935303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOUDEH KHAYAM-BASHI NP

Provider Business Mailing Address
First Line	:	4237 LONGRIDGE AVE UNIT 103
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-1876
Country	:	US
Telephone Number	:	818-268-7089
Fax Number	:

Provider Business Practice Location Address
First Line	:	4237 LONGRIDGE AVE UNIT 103
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-1876
Country	:	US
Telephone Number	:	818-268-7089
Fax Number	:

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

Provider Enumeration Date	:	02/12/2022
Last Update Date	:	02/12/2022

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