Basic Information
| Provider Information | |||||||||
| NPI: | 1992327712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOGHADAM | ||||||||
| FirstName: | MAHMOUD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2345 E PRATER WAY STE 207 | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894349634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028359870 | ||||||||
| FaxNumber: | 7028359883 | ||||||||
| Practice Location | |||||||||
| Address1: | 6850 N DURANGO DR STE 208 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891494596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028359870 | ||||||||
| FaxNumber: | 7028359883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2020 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | 823272 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363L00000X | 823272 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.