Provider Demographics
NPI:1245345933
Name:MOGIL, ADAM GREGORY (PA-C)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:GREGORY
Last Name:MOGIL
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 1:5522 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3437
Mailing Address - Country:US
Mailing Address - Phone:818-990-5020
Mailing Address - Fax:818-990-8549
Practice Address - Street 1:5522 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3437
Practice Address - Country:US
Practice Address - Phone:818-990-5020
Practice Address - Fax:818-990-8549
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ71503Medicare UPIN