Provider Demographics
NPI:1700261682
Name:EBNEYAMIN, SOHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SOHA
Middle Name:
Last Name:EBNEYAMIN
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 1:1537 15TH ST APT 106
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3350
Mailing Address - Country:US
Mailing Address - Phone:310-804-0743
Mailing Address - Fax:
Practice Address - Street 1:1537 15TH ST APT 106
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3350
Practice Address - Country:US
Practice Address - Phone:310-804-0743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52633363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical