Healthcare Provider Details

I. General information

NPI: 1679434369
Provider Name (Legal Business Name): SIRANUSH VANESSA KHDRYAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S CENTRAL AVE STE 101B
GLENDALE CA
91204-4375
US

IV. Provider business mailing address

800 S CENTRAL AVE STE 101B
GLENDALE CA
91204-4375
US

V. Phone/Fax

Practice location:
  • Phone: 818-649-1433
  • Fax:
Mailing address:
  • Phone: 818-649-1433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: