Provider Demographics
NPI:1629639984
Name:MEHDAVI, TAMANA
Entity Type:Individual
Prefix:
First Name:TAMANA
Middle Name:
Last Name:MEHDAVI
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 1:651 FOLSOM AVE # A
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-6404
Mailing Address - Country:US
Mailing Address - Phone:510-789-7388
Mailing Address - Fax:
Practice Address - Street 1:22331 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-3911
Practice Address - Country:US
Practice Address - Phone:510-471-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010487363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner