Provider Demographics
NPI:1972573160
Name:MAHIDASHTI, RAQUEL M (DNP)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:M
Last Name:MAHIDASHTI
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 SYLVAN AVE
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2426
Mailing Address - Country:US
Mailing Address - Phone:201-585-0957
Mailing Address - Fax:201-585-0902
Practice Address - Street 1:44 SYLVAN AVE
Practice Address - Street 2:SUITE 2D
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2426
Practice Address - Country:US
Practice Address - Phone:201-585-0957
Practice Address - Fax:201-585-0902
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00127200363L00000X
NY335056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP54331Medicare UPIN
MAP54331Medicare UPIN