Provider Demographics
NPI:1972831451
Name:HYDARA, MUSTAPHA I (ARNP)
Entity Type:Individual
Prefix:MR
First Name:MUSTAPHA
Middle Name:I
Last Name:HYDARA
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13216 SE 263RD PL
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-3548
Mailing Address - Country:US
Mailing Address - Phone:253-347-2665
Mailing Address - Fax:253-631-1375
Practice Address - Street 1:615 W TITUS ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5749
Practice Address - Country:US
Practice Address - Phone:253-670-4234
Practice Address - Fax:253-631-1375
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60125636363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health