Provider Demographics
NPI:1497031710
Name:BORNA, SHADY
Entity Type:Individual
Prefix:
First Name:SHADY
Middle Name:
Last Name:BORNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHADY
Other - Middle Name:BORNA
Other - Last Name:NASSI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:348 S. HAUSER BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3293
Mailing Address - Country:US
Mailing Address - Phone:818-640-9716
Mailing Address - Fax:
Practice Address - Street 1:348 S. HAUSER BLVD APT 102
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-3293
Practice Address - Country:US
Practice Address - Phone:818-640-9716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant