Provider Demographics
NPI:1255880720
Name:KHANDADASH, NILOOFAR (PA-C)
Entity type:Individual
Prefix:
First Name:NILOOFAR
Middle Name:
Last Name:KHANDADASH
Suffix:
Gender:F
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 1:5130 YARMOUTH AVE
Mailing Address - Street 2:APT 27
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3303
Mailing Address - Country:US
Mailing Address - Phone:818-914-8402
Mailing Address - Fax:
Practice Address - Street 1:5130 YARMOUTH AVE
Practice Address - Street 2:APT 27
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3303
Practice Address - Country:US
Practice Address - Phone:818-914-8402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant