Provider Demographics
NPI:1700428711
Name:IBRAHIM, ISLAM GAMAL (PA-C)
Entity Type:Individual
Prefix:
First Name:ISLAM
Middle Name:GAMAL
Last Name:IBRAHIM
Suffix:
Gender:M
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 1:1415 LEDGESTONE LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3566
Mailing Address - Country:US
Mailing Address - Phone:305-528-1507
Mailing Address - Fax:
Practice Address - Street 1:1415 LEDGESTONE LN
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3566
Practice Address - Country:US
Practice Address - Phone:305-528-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty