Provider Demographics
NPI:1003954694
Name:MAUDE, MAX MEHRDAD (PA)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:MEHRDAD
Last Name:MAUDE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7423
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91802-7423
Mailing Address - Country:US
Mailing Address - Phone:209-416-6917
Mailing Address - Fax:
Practice Address - Street 1:350 S OAK AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3519
Practice Address - Country:US
Practice Address - Phone:209-848-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16451OtherPHYSICIAN ASSISTANT
CAPA16451Medicaid
CAPA16451OtherPHYSICIAN ASSISTANT
CAPA16451Medicaid
CABP474Medicare PIN
CA0PA164510Medicare PIN
CAAU965WMedicare PIN