Provider Demographics
NPI:1790127298
Name:KAKAVAND, JEILA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JEILA
Middle Name:MARIE
Last Name:KAKAVAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JEILA
Other - Middle Name:
Other - Last Name:KERDAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:R PA-C
Mailing Address - Street 1:8805 STONEBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9380
Mailing Address - Country:US
Mailing Address - Phone:716-689-4315
Mailing Address - Fax:
Practice Address - Street 1:3925 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1738
Practice Address - Country:US
Practice Address - Phone:716-250-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23 016726363A00000X
CA52220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant