Provider Demographics
NPI:1598123945
Name:EDJLALI, AHRESH (PA-C)
Entity Type:Individual
Prefix:
First Name:AHRESH
Middle Name:
Last Name:EDJLALI
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 1:1140 KANE CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BAY HARBOR ISLANDS
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 KANE CONCOURSE
Practice Address - Street 2:
Practice Address - City:BAY HARBOR ISLANDS
Practice Address - State:FL
Practice Address - Zip Code:33154-2045
Practice Address - Country:US
Practice Address - Phone:305-861-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-31
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant