Provider Demographics
NPI:1396071908
Name:FARAHVASHI, SHIVA (PA)
Entity type:Individual
Prefix:MRS
First Name:SHIVA
Middle Name:
Last Name:FARAHVASHI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16661 VENTURA BLVD
Mailing Address - Street 2:STE 824
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4802
Mailing Address - Country:US
Mailing Address - Phone:818-784-4100
Mailing Address - Fax:
Practice Address - Street 1:450 N. BEDORD DR. STE 209
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4306
Practice Address - Country:US
Practice Address - Phone:516-404-5109
Practice Address - Fax:323-370-6817
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20575363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical