Provider Demographics
NPI:1982900718
Name:AIDASANI, MIRA B
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:B
Last Name:AIDASANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:B
Other - Last Name:AIDASANI-DIWATA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2016 MORSE AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2135
Mailing Address - Country:US
Mailing Address - Phone:916-973-5000
Mailing Address - Fax:877-738-4262
Practice Address - Street 1:2016 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2135
Practice Address - Country:US
Practice Address - Phone:916-973-5000
Practice Address - Fax:877-738-4262
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily