Provider Demographics
NPI:1609485267
Name:TAVAKOLIAN, AZADEH
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:TAVAKOLIAN
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 1:2821 GEORGE BUSH HWY STE 500
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4278
Mailing Address - Country:US
Mailing Address - Phone:469-206-6957
Mailing Address - Fax:469-206-6953
Practice Address - Street 1:2821 GEORGE BUSH HWY STE 500
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4278
Practice Address - Country:US
Practice Address - Phone:469-206-6957
Practice Address - Fax:469-206-6953
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily