Provider Demographics
NPI:1477977130
Name:JARRAHIZADEH, REZA
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:JARRAHIZADEH
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-4990
Mailing Address - Fax:
Practice Address - Street 1:13523 PLAZA ROAD EXT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8921
Practice Address - Country:US
Practice Address - Phone:704-316-4990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant