Provider Demographics
NPI:1063835692
Name:ODA, THAGHAR MANSOUR (FNP)
Entity Type:Individual
Prefix:
First Name:THAGHAR
Middle Name:MANSOUR
Last Name:ODA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:
Practice Address - Street 1:1111 W CHASE AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-5710
Practice Address - Country:US
Practice Address - Phone:619-515-2499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF95000205363LF0000X
CA95000205363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily