Provider Demographics
NPI:1417294265
Name:FASSIH, TALAR (PA)
Entity Type:Individual
Prefix:
First Name:TALAR
Middle Name:
Last Name:FASSIH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TALAR
Other - Middle Name:
Other - Last Name:AIVAZIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-0179
Mailing Address - Country:US
Mailing Address - Phone:818-631-7399
Mailing Address - Fax:
Practice Address - Street 1:20905 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1743
Practice Address - Country:US
Practice Address - Phone:818-564-4961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant