Healthcare Provider Details

I. General information

NPI: 1578820122
Provider Name (Legal Business Name): GOHAR AYVAZYAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N BEDFORD DR STE 312
BEVERLY HILLS CA
90210-4314
US

IV. Provider business mailing address

435 N BEDFORD DR STE 212
BEVERLY HILLS CA
90210-4321
US

V. Phone/Fax

Practice location:
  • Phone: 310-858-5090
  • Fax: 310-276-5508
Mailing address:
  • Phone: 310-858-5090
  • Fax: 310-888-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: