Provider Demographics
NPI:1205246782
Name:POULLATH, ISRAA QASIM
Entity type:Individual
Prefix:
First Name:ISRAA
Middle Name:QASIM
Last Name:POULLATH
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 1:42001 MARGARITA RD
Mailing Address - Street 2:APT#220
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5772
Mailing Address - Country:US
Mailing Address - Phone:254-421-6533
Mailing Address - Fax:
Practice Address - Street 1:42001 MARGARITA RD
Practice Address - Street 2:APT#220
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5772
Practice Address - Country:US
Practice Address - Phone:254-421-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97436254F84077146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA97436254F84077OtherMEDICAL