Provider Demographics
NPI:1942072426
Name:NOUR, MOHAMED
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:NOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4734 E EDISON ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2721
Mailing Address - Country:US
Mailing Address - Phone:520-312-9436
Mailing Address - Fax:
Practice Address - Street 1:4734 E EDISON ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2721
Practice Address - Country:US
Practice Address - Phone:520-312-9436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL12794H310400000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ205088OtherDES ARIZONA AHCCCS