Provider Demographics
NPI:1215126701
Name:NAZIR, MARYAM (RDHAP)
Entity type:Individual
Prefix:MISS
First Name:MARYAM
Middle Name:
Last Name:NAZIR
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:MISS
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:HESARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDHAP
Mailing Address - Street 1:10753 MOUNTAINER AVE
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042
Mailing Address - Country:US
Mailing Address - Phone:916-622-2894
Mailing Address - Fax:
Practice Address - Street 1:10753 MOUNTAINER AVE
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042
Practice Address - Country:US
Practice Address - Phone:916-622-2894
Practice Address - Fax:916-622-2894
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY00090-01OtherMEDICAL
CA523842Medicare PIN