Provider Demographics
NPI:1083282206
Name:JAMALUDEEN, NISAR FATHIMA (PT)
Entity Type:Individual
Prefix:
First Name:NISAR FATHIMA
Middle Name:
Last Name:JAMALUDEEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448P COUNTRYBROOK LOOP
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4498
Mailing Address - Country:US
Mailing Address - Phone:925-913-0384
Mailing Address - Fax:
Practice Address - Street 1:1333 WILLOW PASS RD STE 110
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5225
Practice Address - Country:US
Practice Address - Phone:925-676-7431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist