Healthcare Provider Details

I. General information

NPI: 1639574395
Provider Name (Legal Business Name): MAHNAZ SHAMBAYATI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 ADAMS AVE
COSTA MESA CA
92626-4958
US

IV. Provider business mailing address

20151 SW BIRCH ST STE 100
NEWPORT BEACH CA
92660-1794
US

V. Phone/Fax

Practice location:
  • Phone: 949-270-2100
  • Fax: 949-650-4458
Mailing address:
  • Phone: 949-270-2100
  • Fax: 949-650-4458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67676
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA67676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: