Provider Demographics
NPI:1518078427
Name:MOGHADASI, SHAHRAM (PA)
Entity Type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:MOGHADASI
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 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7033
Mailing Address - Fax:818-830-7280
Practice Address - Street 1:8902 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-6401
Practice Address - Country:US
Practice Address - Phone:818-830-7033
Practice Address - Fax:818-830-7280
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70468FMedicaid
CAHAP70468FOtherHAP GRP #
CABCP70468FOtherCDC GRP#
CAPA15877OtherLICENSE #
CAHAP70468FOtherHAP GRP #
CAWPA15877AMedicare ID - Type UnspecifiedM/CARE PROV #