Provider Demographics
NPI:1518949759
Name:KHALILI, SOPHIA (PA-C)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:KHALILI
Suffix:
Gender:F
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 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-837-8905
Mailing Address - Fax:760-837-8956
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-837-8905
Practice Address - Fax:760-837-8956
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003957363A00000X
CAPA22183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160C97618OtherBCBSM
MI1104840529OtherBCBS - BMG
MI1518949759Medicaid
MIM20520097 - BMGMedicare PIN
MI1518949759Medicaid
MIP14380004Medicare PIN
MIM20520097Medicare PIN