Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | A73058 | CA |
Y | 111NI0900X | Internist | A73058 | CA |
NPI | 1003339722 |
---|---|
Provider Name | Soheila Benrazavi |
First Address | Santa Rosa, CA 95405-7868 |
Second Address | Santa Rosa, CA 95405-9540 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2017 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00000000000 | NO OTHER PROVIDER NUMBER ARE AVAILABLE (01) | |
000000000000000 | NO OTHER PROVIDER ID (01) |