Provider Demographics
NPI:1225457260
Name:FOROUZ JOWKAR LLC
Entity Type:Organization
Organization Name:FOROUZ JOWKAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FOROUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:JOWKAR
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:505-424-9172
Mailing Address - Street 1:1925 ASPEN DR
Mailing Address - Street 2:# 100B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5459
Mailing Address - Country:US
Mailing Address - Phone:505-424-9172
Mailing Address - Fax:505-438-1814
Practice Address - Street 1:1925 ASPEN DR
Practice Address - Street 2:# 100B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5459
Practice Address - Country:US
Practice Address - Phone:505-424-9172
Practice Address - Fax:505-438-1814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2008-0051363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty