Provider Demographics
NPI:1417669532
Name:YAZDANPOUR, NICOLE (AGACNP-BC,RNFA, CNOR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:YAZDANPOUR
Suffix:
Gender:F
Credentials:AGACNP-BC,RNFA, CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1062 KAUNOA ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3530
Mailing Address - Country:US
Mailing Address - Phone:808-429-4943
Mailing Address - Fax:
Practice Address - Street 1:99-115 AIEA HEIGHTS DR STE 276
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3967
Practice Address - Country:US
Practice Address - Phone:808-784-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-71056163WR0006X
HIAPRN-3954363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1417669532Medicaid