Provider Demographics
NPI:1780652818
Name:AHMED, MARK-MUSHTAQ JAVED (NP)
Entity Type:Individual
Prefix:MR
First Name:MARK-MUSHTAQ
Middle Name:JAVED
Last Name:AHMED
Suffix:
Gender:M
Credentials:NP
Other - Prefix:MR
Other - First Name:MUSHTAQ
Other - Middle Name:JAVED
Other - Last Name:AHMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:23 GOOSE HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-2506
Mailing Address - Country:US
Mailing Address - Phone:916-575-9392
Mailing Address - Fax:
Practice Address - Street 1:5342 DUDLEY BLVD
Practice Address - Street 2:
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652-1012
Practice Address - Country:US
Practice Address - Phone:916-561-7473
Practice Address - Fax:916-561-7440
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA466078363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner