Provider Demographics
NPI:1295210953
Name:BAISA, ASTA IAH (RN, PHN, FNP-C)
Entity Type:Individual
Prefix:
First Name:ASTA
Middle Name:IAH
Last Name:BAISA
Suffix:
Gender:F
Credentials:RN, PHN, FNP-C
Other - Prefix:
Other - First Name:ASTA
Other - Middle Name:IAH
Other - Last Name:HAMAN-DICKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2806 MARINA BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4048
Mailing Address - Country:US
Mailing Address - Phone:510-967-6703
Mailing Address - Fax:
Practice Address - Street 1:2455 SAN RAMON VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1601
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95086184163W00000X
CA95008367363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse