Provider Demographics
NPI:1043718653
Name:MOTEVALLI, MAHSA
Entity Type:Individual
Prefix:
First Name:MAHSA
Middle Name:
Last Name:MOTEVALLI
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 1:8600 OLD GEORGETOWN RD FL 6
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1422
Mailing Address - Country:US
Mailing Address - Phone:301-896-3982
Mailing Address - Fax:
Practice Address - Street 1:8600 OLD GEORGETOWN RD FL 6
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814
Practice Address - Country:US
Practice Address - Phone:301-896-3982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205493363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily