Provider Demographics
NPI:1497808497
Name:JAGNE, EBRAHIM MAMOUR SR (PA)
Entity Type:Individual
Prefix:DR
First Name:EBRAHIM
Middle Name:MAMOUR
Last Name:JAGNE
Suffix:SR
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 1:1137 W 58TH PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3702
Mailing Address - Country:US
Mailing Address - Phone:310-283-1279
Mailing Address - Fax:
Practice Address - Street 1:1329 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-6310
Practice Address - Country:US
Practice Address - Phone:714-547-6542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 12322363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical