Provider Demographics
NPI:1700994449
Name:MENACHEM, TALI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TALI
Middle Name:
Last Name:MENACHEM
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 1:11821 GOSHEN AVE
Mailing Address - Street 2:#4
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6344
Mailing Address - Country:US
Mailing Address - Phone:323-369-6779
Mailing Address - Fax:
Practice Address - Street 1:11821 GOSHEN AVE
Practice Address - Street 2:#4
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6344
Practice Address - Country:US
Practice Address - Phone:323-369-6779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant