Provider Demographics
NPI:1932129707
Name:BAZAVAN, IRINA (NP)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:BAZAVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 GRANT AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-7001
Mailing Address - Country:US
Mailing Address - Phone:415-899-9800
Mailing Address - Fax:415-899-9805
Practice Address - Street 1:750 GRANT AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-7001
Practice Address - Country:US
Practice Address - Phone:415-899-9800
Practice Address - Fax:415-899-9805
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8749363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8749OtherNP LICENCE
CARN3855290Medicaid
CA385529OtherRN LICENSE
CA385529OtherRN LICENSE
P30203Medicare UPIN
ZZZ27859ZMedicare ID - Type Unspecified