Provider Demographics
NPI:1245000819
Name:AHOURAIE, BOBAK (PA)
Entity type:Individual
Prefix:
First Name:BOBAK
Middle Name:
Last Name:AHOURAIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JUNE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-2621
Mailing Address - Country:US
Mailing Address - Phone:207-490-7000
Mailing Address - Fax:207-490-7002
Practice Address - Street 1:25 JUNE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2621
Practice Address - Country:US
Practice Address - Phone:207-490-7000
Practice Address - Fax:207-490-7002
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant