Provider Demographics
NPI:1932256849
Name:MIRSHAHZADEH, MANDANA (CRNP)
Entity type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:MIRSHAHZADEH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3413
Mailing Address - Country:US
Mailing Address - Phone:760-737-6960
Mailing Address - Fax:
Practice Address - Street 1:26926 CHERRY HILLS BLVD STE B
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586
Practice Address - Country:US
Practice Address - Phone:951-216-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009248363LW0102X
CANP95004348363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP009248OtherNURSE PRACTITIONER LICENS