Basic Information
| Provider Information | |||||||||
| NPI: | 1144632217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | SOUSAN | ||||||||
| MiddleName: | YAZDI | ||||||||
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| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | YAZDI | ||||||||
| OtherFirstName: | SOUSAN | ||||||||
| OtherMiddleName: | AKHAVAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4371 VERONICA S SHOEMAKER BLVD | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339162216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | 2392783350 | ||||||||
| Practice Location | |||||||||
| Address1: | 8931 COLONIAL CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339057809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399380800 | ||||||||
| FaxNumber: | 2399380890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2014 | ||||||||
| LastUpdateDate: | 05/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9293083 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.