Provider Demographics
NPI:1497386023
Name:MOTAFFAF, FARZANEH
Entity Type:Individual
Prefix:
First Name:FARZANEH
Middle Name:
Last Name:MOTAFFAF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13425 FM 620 N APT 1032
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-1014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13425 FM 620 N APT 1032
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-1014
Practice Address - Country:US
Practice Address - Phone:512-701-3617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty