Provider Demographics
NPI:1457141764
Name:MOGES, KASSAHUN G
Entity type:Individual
Prefix:
First Name:KASSAHUN
Middle Name:G
Last Name:MOGES
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28494 OLD SPANISH TRL
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91390-5260
Mailing Address - Country:US
Mailing Address - Phone:661-505-0325
Mailing Address - Fax:
Practice Address - Street 1:21515 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6501
Practice Address - Country:US
Practice Address - Phone:480-604-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-09
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95035016363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health