Provider Demographics
NPI:1376324103
Name:GHAZAL, ADHAM
Entity Type:Individual
Prefix:
First Name:ADHAM
Middle Name:
Last Name:GHAZAL
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 1:3402 WYOMING BLVD NE BLDG 340206
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4400
Mailing Address - Country:US
Mailing Address - Phone:469-927-7668
Mailing Address - Fax:
Practice Address - Street 1:2250 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1402
Practice Address - Country:US
Practice Address - Phone:469-927-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95352338163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult