Provider Demographics
NPI:1346707296
Name:AHMAT, DASTU I
Entity Type:Individual
Prefix:
First Name:DASTU
Middle Name:I
Last Name:AHMAT
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 1:55 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2640
Mailing Address - Country:US
Mailing Address - Phone:503-984-6216
Mailing Address - Fax:
Practice Address - Street 1:55 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2640
Practice Address - Country:US
Practice Address - Phone:503-984-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11146311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home