Provider Demographics
NPI:1518507987
Name:MASHKOURI, KAVEH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KAVEH
Middle Name:
Last Name:MASHKOURI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27700 MEDICAL CENTER RD
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6426
Mailing Address - Country:US
Mailing Address - Phone:949-364-1400
Mailing Address - Fax:
Practice Address - Street 1:27700 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6426
Practice Address - Country:US
Practice Address - Phone:949-364-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant