Provider Demographics
NPI:1205210309
Name:GRIGORIAN-AVAKIAN, MARINE (PA)
Entity Type:Individual
Prefix:
First Name:MARINE
Middle Name:
Last Name:GRIGORIAN-AVAKIAN
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 1:7050 N RECREATION AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8001
Mailing Address - Country:US
Mailing Address - Phone:559-325-3515
Mailing Address - Fax:
Practice Address - Street 1:7050 N RECREATION AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8001
Practice Address - Country:US
Practice Address - Phone:559-325-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant