Provider Demographics
NPI:1558462515
Name:AKBARI, MOHAMMAD ALI (PA-C)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ALI
Last Name:AKBARI
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 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:24853 ALESSANDRO BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-6102
Practice Address - Country:US
Practice Address - Phone:951-571-8518
Practice Address - Fax:562-485-7748
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17622363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFFECTIVE: 12/7/2011Medicaid
CAEFFECTIVE: 12/7/2011Medicaid
CAFR695YMedicare PIN
CAQ30045Medicare UPIN
CAFR695XMedicare PIN