Provider Demographics
NPI:1942943857
Name:PAHLEVAN, SOGOL (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SOGOL
Middle Name:
Last Name:PAHLEVAN
Suffix:
Gender:F
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 1:21401 ARBORWOOD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6410
Mailing Address - Country:US
Mailing Address - Phone:949-413-0054
Mailing Address - Fax:
Practice Address - Street 1:8201 NEWMAN AVE STE 301
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7043
Practice Address - Country:US
Practice Address - Phone:949-413-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA61003OtherCALIFORNIA PHYSICIAN ASSISTANT BOARD