Provider Demographics
NPI:1780643528
Name:MOSTAFANIA, SHAHAB (PA)
Entity type:Individual
Prefix:MR
First Name:SHAHAB
Middle Name:
Last Name:MOSTAFANIA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:MOSTAFANIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:401 W LOS FELIZ RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2769
Mailing Address - Country:US
Mailing Address - Phone:818-296-0201
Mailing Address - Fax:
Practice Address - Street 1:401 W LOS FELIZ RD STE E
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2769
Practice Address - Country:US
Practice Address - Phone:818-296-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16378363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADK089XMedicare PIN