Provider Demographics
NPI:1093570731
Name:MARDIROSSIAN, TALAR
Entity Type:Individual
Prefix:
First Name:TALAR
Middle Name:
Last Name:MARDIROSSIAN
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 1:5805 SEPULVEDA BLVD STE 690
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-2522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5805 SEPULVEDA BLVD STE 690
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-2522
Practice Address - Country:US
Practice Address - Phone:818-900-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028682363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner