Provider Demographics
NPI:1225671845
Name:BARADARAN, KIMYA
Entity Type:Individual
Prefix:
First Name:KIMYA
Middle Name:
Last Name:BARADARAN
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 1:75 ROWLAND WAY
Mailing Address - Street 2:250
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945
Mailing Address - Country:US
Mailing Address - Phone:415-878-2910
Mailing Address - Fax:415-878-2916
Practice Address - Street 1:75 ROWLAND WAY STE 250
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5018
Practice Address - Country:US
Practice Address - Phone:415-927-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA59049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program