MEDICARE: MRS. TAMILLA RASULOV PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA16191	CA

General Provider Information

NPI Number	:	1871601682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TAMILLA RASULOV PA

Provider Business Mailing Address
First Line	:	12840 RIVERSIDE DR
Second Line	:	SUITE 300
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3327
Country	:	US
Telephone Number	:	818-655-9900
Fax Number	:	818-655-9909

Provider Business Practice Location Address
First Line	:	12840 RIVERSIDE DR
Second Line	:	SUITE 300
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3327
Country	:	US
Telephone Number	:	818-655-9900
Fax Number	:	818-655-9909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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