Provider Demographics
NPI:1730753534
Name:MIRZA, SABRINA
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:
Last Name:MIRZA
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 1:1513 E FLORIDA AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-6138
Mailing Address - Country:US
Mailing Address - Phone:630-217-8749
Mailing Address - Fax:
Practice Address - Street 1:701 DEVONSHIRE DR STE B16-18
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7337
Practice Address - Country:US
Practice Address - Phone:217-531-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date: