Provider Demographics
NPI:1871258020
Name:SHAHRIYARI, SHABNAM
Entity Type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:SHAHRIYARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23912 COPENHAGEN ST
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-3022
Mailing Address - Country:US
Mailing Address - Phone:714-430-0107
Mailing Address - Fax:
Practice Address - Street 1:140 E COMMONWEALTH AVE STE 101
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1905
Practice Address - Country:US
Practice Address - Phone:714-773-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62095363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant