Provider Demographics
NPI:1689012718
Name:DELUCIA, MARYAM NASERI (PA)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:NASERI
Last Name:DELUCIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARYAM
Other - Middle Name:NASERI
Other - Last Name:JABARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-853-5745
Mailing Address - Fax:
Practice Address - Street 1:2490 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4122
Practice Address - Country:US
Practice Address - Phone:650-404-8250
Practice Address - Fax:650-404-8205
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22960363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical