Healthcare Provider Details

I. General information

NPI: 1295050920
Provider Name (Legal Business Name): TALINE GRACE KRIKORIAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 MICHELSON DR STE 100
IRVINE CA
92612-0693
US

IV. Provider business mailing address

400 W CALIFORNIA AVE UNIT 110
GLENDALE CA
91203-2925
US

V. Phone/Fax

Practice location:
  • Phone: 855-229-6460
  • Fax: 503-893-6847
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61119226
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20866
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61119226
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA20866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: