Provider Demographics
NPI:1902820152
Name:KHORRAM, BABAK (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:BABAK
Middle Name:
Last Name:KHORRAM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 ROCKPORT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1050
Mailing Address - Country:US
Mailing Address - Phone:562-868-0733
Mailing Address - Fax:
Practice Address - Street 1:13330 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3251
Practice Address - Country:US
Practice Address - Phone:562-868-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14508363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14508Medicaid
CAPA14508Medicaid