Healthcare Provider Details

I. General information

NPI: 1467000802
Provider Name (Legal Business Name): SABA SADAT KHANSARI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 N WESTERN AVE
LOS ANGELES CA
90027-3403
US

IV. Provider business mailing address

6255 W SUNSET BLVD FL 21
LOS ANGELES CA
90028-7422
US

V. Phone/Fax

Practice location:
  • Phone: 855-783-2434
  • Fax:
Mailing address:
  • Phone: 323-860-5200
  • Fax: 323-467-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60973
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA60973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: