Provider Demographics
NPI:1689451197
Name:MIRZA, JASIA
Entity Type:Individual
Prefix:
First Name:JASIA
Middle Name:
Last Name:MIRZA
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 1:276 SOHMER PL
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-3626
Mailing Address - Country:US
Mailing Address - Phone:347-209-0568
Mailing Address - Fax:
Practice Address - Street 1:276 SOHMER PL
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-3626
Practice Address - Country:US
Practice Address - Phone:347-209-0568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist