Provider Demographics
NPI:1073580866
Name:MEHTA, SMITA DARSHAN (PA)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:DARSHAN
Last Name:MEHTA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 SYCAMORE DR
Mailing Address - Street 2:SUITE 204-205
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1207
Mailing Address - Country:US
Mailing Address - Phone:805-578-9620
Mailing Address - Fax:805-955-0498
Practice Address - Street 1:2925 SYCAMORE DR
Practice Address - Street 2:SUITE 204-205
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1207
Practice Address - Country:US
Practice Address - Phone:805-578-9620
Practice Address - Fax:805-955-0498
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA15279AOtherMEDICARE PTAN