Provider Demographics
NPI:1619250172
Name:MOTAHEDEH, MAZYAR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MAZYAR
Middle Name:
Last Name:MOTAHEDEH
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 1:8556 GREGORY WAY APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1725
Mailing Address - Country:US
Mailing Address - Phone:310-351-3826
Mailing Address - Fax:310-855-9429
Practice Address - Street 1:8631 W. 3RD STREET. STE. #715E
Practice Address - Street 2:CEDAR SINAI MEDICAL TOWERS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:310-278-8330
Practice Address - Fax:310-275-7595
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant