Provider Demographics
NPI:1821417924
Name:AKHAVAN SHAHR ASHOUB, LEILA (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:AKHAVAN SHAHR ASHOUB
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 HIDDEN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2477
Mailing Address - Country:US
Mailing Address - Phone:315-744-3132
Mailing Address - Fax:
Practice Address - Street 1:14523 NORTHLINE ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195
Practice Address - Country:US
Practice Address - Phone:734-324-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant