Provider Demographics
NPI:1316202252
Name:SPORGAN, NAJIBE ESRAEIL (PA-C)
Entity Type:Individual
Prefix:
First Name:NAJIBE
Middle Name:ESRAEIL
Last Name:SPORGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NAJIBEH
Other - Middle Name:ESRAEIL
Other - Last Name:SOPORGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:1409 E BRIGGSMORE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2707
Practice Address - Country:US
Practice Address - Phone:209-524-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316202252Medicaid
GL898ZMedicare PIN
CA1316202252Medicaid