Basic Information
| Provider Information | |||||||||
| NPI: | 1164995163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEYDARI | ||||||||
| FirstName: | SAHAR | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 N SAN SABA | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107042011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 N SANTA ROSA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107042011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2019 | ||||||||
| LastUpdateDate: | 12/04/2019 | ||||||||
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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 | 363A00000X | PA12628 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 398448603 | 05 | TX | MEDICAID | 398448604 | 01 | TX | CSHCN | OTHER |