Provider Demographics
NPI:1659776557
Name:MOGHADDAMI, MAHMOUD (APRN)
Entity Type:Individual
Prefix:MR
First Name:MAHMOUD
Middle Name:
Last Name:MOGHADDAMI
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 E FT LOWELL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85749
Mailing Address - Country:US
Mailing Address - Phone:520-202-1960
Mailing Address - Fax:
Practice Address - Street 1:6375 E TANQUE VERDE RD STE 140
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3863
Practice Address - Country:US
Practice Address - Phone:520-885-4679
Practice Address - Fax:520-296-9556
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS76463363LP0808X
AZAP8529363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health