Provider Demographics
NPI:1376889428
Name:SHAHRAVESH, NATASHA SADAT (NP)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:SADAT
Last Name:SHAHRAVESH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 FROST ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2701
Mailing Address - Country:US
Mailing Address - Phone:949-202-8354
Mailing Address - Fax:
Practice Address - Street 1:7901 FROST ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2701
Practice Address - Country:US
Practice Address - Phone:949-202-8354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP21981363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner