Provider Demographics
NPI:1912625328
Name:MOSHAYEDI, POUPAK
Entity Type:Individual
Prefix:
First Name:POUPAK
Middle Name:
Last Name:MOSHAYEDI
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 1:8191 HOLLIDAY RD
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-6499
Mailing Address - Country:US
Mailing Address - Phone:817-770-5189
Mailing Address - Fax:
Practice Address - Street 1:5200 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7709
Practice Address - Country:US
Practice Address - Phone:469-419-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF06221831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily