Provider Demographics
NPI:1700450590
Name:MOGHTADERIZADEH, ARAZUE NICOLETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:ARAZUE
Middle Name:NICOLETTE
Last Name:MOGHTADERIZADEH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 MOWRY AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1605
Mailing Address - Country:US
Mailing Address - Phone:510-818-1160
Mailing Address - Fax:510-818-1195
Practice Address - Street 1:2500 MOWRY AVE STE 222
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1605
Practice Address - Country:US
Practice Address - Phone:510-818-1160
Practice Address - Fax:510-818-1195
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant