Provider Demographics
NPI:1407176910
Name:FARAHMANDIAN, RENE (PA)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:FARAHMANDIAN
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 1:2021 SANTA MONICA BLVD STE 600E
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2166
Mailing Address - Country:US
Mailing Address - Phone:310-828-2282
Mailing Address - Fax:310-828-8504
Practice Address - Street 1:2021 SANTA MONICA BLVD STE 600E
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2166
Practice Address - Country:US
Practice Address - Phone:310-828-2282
Practice Address - Fax:310-828-8504
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17092363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical