Provider Demographics
NPI:1093072142
Name:NAMIRANIAN, AZADEH (PA-C)
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:NAMIRANIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2213
Mailing Address - Fax:214-231-2159
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:SUITE 610
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-345-7398
Practice Address - Fax:214-345-4264
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22234363AM0700X, 363AS0400X
TXPA07659363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA270096920OtherTAX ID
CAGR0102820Medicaid
CA270096920OtherTAX ID