Provider Demographics
NPI:1083210017
Name:ALGAZZALI, AHLAM MAHMOOD (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:AHLAM
Middle Name:MAHMOOD
Last Name:ALGAZZALI
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-204-1844
Mailing Address - Fax:510-247-6492
Practice Address - Street 1:20101 LAKE CHABOT RD FL 3
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5305
Practice Address - Country:US
Practice Address - Phone:510-204-1844
Practice Address - Fax:510-247-6492
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA59807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant