Provider Demographics
NPI:1932483062
Name:YAZDANI, ROYA (PA)
Entity Type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:YAZDANI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8230 WALNUT HILL LN STE 414
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4469
Mailing Address - Country:US
Mailing Address - Phone:214-691-8306
Mailing Address - Fax:214-691-3967
Practice Address - Street 1:8230 WALNUT HILL LN STE 414
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4469
Practice Address - Country:US
Practice Address - Phone:214-691-8306
Practice Address - Fax:214-691-3967
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01001631OtherMEDICARE PALMETTO RR
TX2878498-01Medicaid
TX862N97OtherBCBS OF TEXAS
TX0016SHOtherBCBS OF TEXAS
TX2034587-03Medicaid
TXD07564OtherMEDICARE PALMETTO RR
TXTXB141152Medicare PIN
TX2878498-01Medicaid
TX279141YKP5Medicare PIN
TXP01001631OtherMEDICARE PALMETTO RR