Healthcare Provider Details

I. General information

NPI: 1548295280
Provider Name (Legal Business Name): PANTEHA MEDHAT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CORPORATE DR SUITE 100
LADERA RANCH CA
92694-2106
US

IV. Provider business mailing address

600 CORPORATE DR SUITE 100
LADERA RANCH CA
92694-2106
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-3940
  • Fax: 949-364-3931
Mailing address:
  • Phone: 949-364-3940
  • Fax: 949-364-3931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP16160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: