Provider Demographics
NPI:1689087892
Name:EJAZ, EHSAN (PA)
Entity Type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:EJAZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 Y ST STE 3740
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-6512
Mailing Address - Fax:916-703-5368
Practice Address - Street 1:4860 Y ST STE 3740
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-6512
Practice Address - Fax:916-703-5368
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56621207T00000X
246ZE0600X
CA56621363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic