Provider Demographics
NPI:1295203107
Name:FAZILAT, NEGIN (NP)
Entity Type:Individual
Prefix:
First Name:NEGIN
Middle Name:
Last Name:FAZILAT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PEARL
Other - Middle Name:
Other - Last Name:FAZILAT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1245 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5520
Mailing Address - Country:US
Mailing Address - Phone:650-557-8252
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009886363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care