Provider Demographics
NPI:1114108743
Name:SOGGE-KERMANI, MAHMUD SABET (PA-C)
Entity Type:Individual
Prefix:
First Name:MAHMUD
Middle Name:SABET
Last Name:SOGGE-KERMANI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:SOHEIL
Other - Middle Name:S
Other - Last Name:KERMANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:RR 1 BOX 67
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:MT
Mailing Address - Zip Code:59526-9705
Mailing Address - Country:US
Mailing Address - Phone:406-353-3100
Mailing Address - Fax:406-353-3229
Practice Address - Street 1:RR 1 BOX 67
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:MT
Practice Address - Zip Code:59526-9705
Practice Address - Country:US
Practice Address - Phone:406-353-3100
Practice Address - Fax:406-353-3229
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT391363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT391OtherLICENSE NUMBER