Provider Demographics
NPI:1306264999
Name:NEISHABOORI, NASTARAN
Entity type:Individual
Prefix:
First Name:NASTARAN
Middle Name:
Last Name:NEISHABOORI
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 1:1500 NE 15TH AVE APT 443
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-4418
Mailing Address - Country:US
Mailing Address - Phone:832-540-0098
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-893-7692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD222287207ZP0007X
CAA149044207ZP0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology