Provider Demographics
NPI:1376177428
Name:FASAZADEH, MISAGH
Entity Type:Individual
Prefix:
First Name:MISAGH
Middle Name:
Last Name:FASAZADEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S MIDDLE NECK RD APT 2E
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3738
Mailing Address - Country:US
Mailing Address - Phone:818-642-4131
Mailing Address - Fax:
Practice Address - Street 1:140 S MIDDLE NECK RD APT 2E
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3738
Practice Address - Country:US
Practice Address - Phone:818-642-4131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025221363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant