Provider Demographics
NPI:1265459184
Name:BASTANFAR, AZAR S (CERTIFIED NURSE PRAC)
Entity Type:Individual
Prefix:
First Name:AZAR
Middle Name:S
Last Name:BASTANFAR
Suffix:
Gender:F
Credentials:CERTIFIED NURSE PRAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE #54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4433
Mailing Address - Country:US
Mailing Address - Phone:858-784-5888
Mailing Address - Fax:760-414-3713
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1207
Practice Address - Country:US
Practice Address - Phone:858-453-0753
Practice Address - Fax:760-414-3713
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA538431363LX0001X
CA9526363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP79976Medicare UPIN