Healthcare Provider Details

I. General information

NPI: 1871258020
Provider Name (Legal Business Name): SHABNAM SHAHRIYARI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 01/26/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E COMMONWEALTH AVE STE 101
FULLERTON CA
92832-1905
US

IV. Provider business mailing address

23912 COPENHAGEN ST
MISSION VIEJO CA
92691-3022
US

V. Phone/Fax

Practice location:
  • Phone: 714-773-4111
  • Fax:
Mailing address:
  • Phone: 714-430-0107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: