Provider Demographics
NPI:1497176499
Name:YAZDANPANAH, NIMA
Entity Type:Individual
Prefix:
First Name:NIMA
Middle Name:
Last Name:YAZDANPANAH
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 1:4070 SPARROW ROCK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-3286
Mailing Address - Country:US
Mailing Address - Phone:702-592-2132
Mailing Address - Fax:
Practice Address - Street 1:4880 W UNIVERSITY AVE STE B5
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3830
Practice Address - Country:US
Practice Address - Phone:702-826-2890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV103K00000XMedicaid