Provider Demographics
NPI:1740740372
Name:DERISS, MOJAN R (PA-C)
Entity Type:Individual
Prefix:
First Name:MOJAN
Middle Name:R
Last Name:DERISS
Suffix:
Gender:F
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 1:32144 AGOURA RD STE 106
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4040
Mailing Address - Country:US
Mailing Address - Phone:805-214-1012
Mailing Address - Fax:
Practice Address - Street 1:32144 AGOURA RD STE 106
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4040
Practice Address - Country:US
Practice Address - Phone:805-379-3376
Practice Address - Fax:805-379-3267
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2023-09-07
Deactivation Date:2020-05-22
Deactivation Code:
Reactivation Date:2021-04-28
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CAPA60028207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatology