Provider Demographics
NPI:1174230494
Name:MEDAWAR, AIDA EMILY
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:EMILY
Last Name:MEDAWAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27800 MEDICAL CENTER RD
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6410
Mailing Address - Country:US
Mailing Address - Phone:909-762-9385
Mailing Address - Fax:
Practice Address - Street 1:27800 MEDICAL CENTER RD STE 110
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6407
Practice Address - Country:US
Practice Address - Phone:949-866-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95164074OtherBRN FURNISHING LICENSE NUMBER