Provider Demographics
NPI:1356873715
Name:AHMADI, SHIVA BAKHTIARI (FNP)
Entity type:Individual
Prefix:MRS
First Name:SHIVA
Middle Name:BAKHTIARI
Last Name:AHMADI
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19782 MACARTHUR BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2417
Mailing Address - Country:US
Mailing Address - Phone:714-545-5550
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE STE G1
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4624
Practice Address - Country:US
Practice Address - Phone:714-545-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000022322164W00000X
TN22322363LF0000X
CA95006733363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily