Provider Demographics
NPI:1578049458
Name:JELVEH, IDA (PA-C, MSPAS, MPH)
Entity Type:Individual
Prefix:MISS
First Name:IDA
Middle Name:
Last Name:JELVEH
Suffix:
Gender:F
Credentials:PA-C, MSPAS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28096 EDELWEISS CT
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7006
Mailing Address - Country:US
Mailing Address - Phone:949-291-0089
Mailing Address - Fax:
Practice Address - Street 1:28096 EDELWEISS CT
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7006
Practice Address - Country:US
Practice Address - Phone:949-291-0089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55747363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty