Provider Demographics
NPI:1689203093
Name:AZAM, FAROOQUE
Entity Type:Individual
Prefix:
First Name:FAROOQUE
Middle Name:
Last Name:AZAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:FAROOQUE
Other - Middle Name:
Other - Last Name:AZAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FAROOQUE AZAM
Mailing Address - Street 1:12450 VAN NUYS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1393
Mailing Address - Country:US
Mailing Address - Phone:818-896-1161
Mailing Address - Fax:818-896-5069
Practice Address - Street 1:12450 VAN NUYS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1393
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:818-896-5069
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014104363LP0808X
CA65014104363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6758Medicaid
CA7420Medicaid
CA7068Medicaid