Provider Demographics
NPI:1295946697
Name:DARVISH, PARVANEH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:PARVANEH
Middle Name:
Last Name:DARVISH
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 1:795 E 2ND ST STE 5
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2007
Mailing Address - Country:US
Mailing Address - Phone:909-865-2565
Mailing Address - Fax:909-865-2955
Practice Address - Street 1:795 E 2ND ST STE 5
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2007
Practice Address - Country:US
Practice Address - Phone:909-865-2565
Practice Address - Fax:909-865-2955
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP82522Medicare UPIN
CAWPA13914CMedicare PIN