Provider Demographics
NPI:1326287244
Name:KESHAVARZ, TAHEREH (PA-C)
Entity Type:Individual
Prefix:
First Name:TAHEREH
Middle Name:
Last Name:KESHAVARZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 1ST AVE S
Mailing Address - Street 2:MERITCARE NEUROSCIENCE CLINIC
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-234-4036
Mailing Address - Fax:701-234-4134
Practice Address - Street 1:700 1ST AVE S
Practice Address - Street 2:MERITCARE NEUROSCIENCE CLINIC -
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-234-4036
Practice Address - Fax:701-234-4134
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0409363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71175Medicaid