Provider Demographics
NPI:1033882782
Name:ETESAM, MAHSA
Entity Type:Individual
Prefix:
First Name:MAHSA
Middle Name:
Last Name:ETESAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 FONT TER
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3592
Mailing Address - Country:US
Mailing Address - Phone:765-337-9896
Mailing Address - Fax:
Practice Address - Street 1:2020 S BASCOM AVE STE 103
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-3269
Practice Address - Country:US
Practice Address - Phone:408-866-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36128111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor