Provider Demographics
NPI:1841585932
Name:YOUNESSI, MARYAM MOFARRAH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:MOFARRAH
Last Name:YOUNESSI
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 1:14521 BENEFIT ST
Mailing Address - Street 2:UNIT 105
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3702
Mailing Address - Country:US
Mailing Address - Phone:818-632-9473
Mailing Address - Fax:
Practice Address - Street 1:11645 WILSHIRE BLVD STE 800
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6811
Practice Address - Country:US
Practice Address - Phone:310-443-5273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant