Provider Demographics
NPI:1982575148
Name:AMIRI, MOHAMMAD A SR
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:A
Last Name:AMIRI
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9527 MOONEN BAY LN
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-3515
Mailing Address - Country:US
Mailing Address - Phone:609-621-5926
Mailing Address - Fax:
Practice Address - Street 1:9527 MOONEN BAY LN
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-3515
Practice Address - Country:US
Practice Address - Phone:609-621-5926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA62743137376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty