Provider Demographics
NPI:1043453814
Name:ISSA, NEDAA N (MD)
Entity type:Individual
Prefix:
First Name:NEDAA
Middle Name:N
Last Name:ISSA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W KETTLEMAN LN STE 200
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4337
Mailing Address - Country:US
Mailing Address - Phone:209-334-8540
Mailing Address - Fax:209-368-2885
Practice Address - Street 1:1901 W KETTLEMAN LN STE 200
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4337
Practice Address - Country:US
Practice Address - Phone:209-334-8540
Practice Address - Fax:209-368-2885
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24915208000000X
CA152298208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023942Medicaid
WV3810023942Medicaid
WVWV1562EMedicare PIN
WVWV1562CMedicare PIN
WVWV1562DMedicare PIN
WVWV1562AMedicare PIN