Provider Demographics
NPI:1740935303
Name:KHAYAM-BASHI, SOUDEH (NP)
Entity type:Individual
Prefix:
First Name:SOUDEH
Middle Name:
Last Name:KHAYAM-BASHI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4237 LONGRIDGE AVE UNIT 103
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1876
Mailing Address - Country:US
Mailing Address - Phone:818-268-7089
Mailing Address - Fax:
Practice Address - Street 1:4237 LONGRIDGE AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-1876
Practice Address - Country:US
Practice Address - Phone:818-268-7089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-12
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95057258363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care