Healthcare Provider Details

I. General information

NPI: 1245359140
Provider Name (Legal Business Name): ABRAHAM DANESHVAR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8851 CENTER DR SUITE 505
LA MESA CA
91942-3017
US

IV. Provider business mailing address

4225 EXECUTIVE SQ STE 450
LA JOLLA CA
92037-8411
US

V. Phone/Fax

Practice location:
  • Phone: 858-810-8000
  • Fax: 858-268-1911
Mailing address:
  • Phone: 858-810-8000
  • Fax: 858-268-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: