Provider Demographics
NPI:1336853712
Name:SHAWAKHA, AHMED A
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:A
Last Name:SHAWAKHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-1124
Mailing Address - Country:US
Mailing Address - Phone:909-794-1040
Mailing Address - Fax:
Practice Address - Street 1:1350 WABASH AVE
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:CA
Practice Address - Zip Code:92359-1124
Practice Address - Country:US
Practice Address - Phone:909-794-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49061225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant