Healthcare Provider Details

I. General information

NPI: 1396210969
Provider Name (Legal Business Name): MOHAMMED SWISSA PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 12/14/2019
Certification Date: 12/14/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

898 N PACIFIC COAST HWY STE 600
EL SEGUNDO CA
90245-2747
US

IV. Provider business mailing address

898 N PACIFIC COAST HWY STE 600
EL SEGUNDO CA
90245-2747
US

V. Phone/Fax

Practice location:
  • Phone: 310-379-2145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57602
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: