Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 95000334 | CA |
NPI | 1003235904 |
---|---|
Provider Name | Lauren Elvira Mirabdollah |
First Address | Santa Maria, CA 93458-7310 |
Second Address | San Luis Obispo, CA 93405-5803 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2014 |
Last Update Date | 24/08/2015 |