Provider Demographics
NPI:1891313441
Name:SAFAEIPOUR, EDWIN (PA C)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:
Last Name:SAFAEIPOUR
Suffix:
Gender:M
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 1:1060 S SHERBOURNE DR APT 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2367
Mailing Address - Country:US
Mailing Address - Phone:310-717-3712
Mailing Address - Fax:
Practice Address - Street 1:1060 S SHERBOURNE DR APT 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2367
Practice Address - Country:US
Practice Address - Phone:310-717-3712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant