Provider Demographics
NPI:1023461696
Name:NIANIARIS, NASTASIA (MD)
Entity type:Individual
Prefix:DR
First Name:NASTASIA
Middle Name:
Last Name:NIANIARIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 W AVENUE Q STE D
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-3891
Mailing Address - Country:US
Mailing Address - Phone:661-272-5656
Mailing Address - Fax:661-272-0909
Practice Address - Street 1:627 W AVENUE Q STE D
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3891
Practice Address - Country:US
Practice Address - Phone:661-272-5656
Practice Address - Fax:661-272-0909
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1622922080A0000X, 208000000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954570184Medicaid