Provider Demographics
NPI:1760670616
Name:ABDELWAHHAB, TAHA MUSTAFA
Entity Type:Individual
Prefix:
First Name:TAHA
Middle Name:MUSTAFA
Last Name:ABDELWAHHAB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 LA SELVA ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3080 LA SELVA ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2109
Practice Address - Country:US
Practice Address - Phone:650-573-2201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA641128163W00000X
CA22045363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse