Provider Demographics
NPI:1205549789
Name:BANANDARGAH, AZITA
Entity type:Individual
Prefix:
First Name:AZITA
Middle Name:
Last Name:BANANDARGAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 RIDGELINE RD W
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8152
Mailing Address - Country:US
Mailing Address - Phone:310-717-0039
Mailing Address - Fax:
Practice Address - Street 1:1003 RIDGELINE RD W
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8152
Practice Address - Country:US
Practice Address - Phone:310-717-0039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95023261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily