Provider Demographics
NPI:1750014189
Name:ISHAK, MARY (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ISHAK
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5900
Mailing Address - Fax:
Practice Address - Street 1:625 S FAIR OAKS AVE STE 400
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2684
Practice Address - Country:US
Practice Address - Phone:626-568-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-04
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA62835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant