Basic Information
| Provider Information | |||||||||
| NPI: | 1447869144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANSOOR | ||||||||
| FirstName: | TARAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 E HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594503000 | ||||||||
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| Practice Location | |||||||||
| Address1: | MSC10 5620 1 UNIVERSITY OF NEW MEXICO ALBUQUERQUE NM | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723342 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2020 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.