Basic Information
| Provider Information | |||||||||
| NPI: | 1750525200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHEZRI | ||||||||
| FirstName: | SHAHRIAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 406 S 30TH AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989023713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099721051 | ||||||||
| FaxNumber: | 5099724166 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 S 30TH AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989023713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099721051 | ||||||||
| FaxNumber: | 5099724166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 05/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | MD60416596 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.