Provider Demographics
NPI:1053829333
Name:MOHAMED, FAISA HASSAN
Entity Type:Individual
Prefix:
First Name:FAISA
Middle Name:HASSAN
Last Name:MOHAMED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ISTARLIN
Other - Middle Name:ABDUSALAM
Other - Last Name:ALI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6035 UNIVERSITY AVE STE 14
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-6342
Mailing Address - Country:US
Mailing Address - Phone:619-573-8244
Mailing Address - Fax:
Practice Address - Street 1:6035 UNIVERSITY AVE STE 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-6342
Practice Address - Country:US
Practice Address - Phone:619-573-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty