Provider Demographics
NPI:1376913806
Name:SHAGHAFI, BRIAN (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SHAGHAFI
Suffix:
Gender:M
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:PO BOX 3956
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 E RIVERSIDE DR
Practice Address - Street 2:APT 366
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7405
Practice Address - Country:US
Practice Address - Phone:510-303-6185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant