Healthcare Provider Details

I. General information

NPI: 1538403597
Provider Name (Legal Business Name): MRS. IMAN JOMAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 06/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S FAIR OAKS AVE STE 208
PASADENA CA
91105-2562
US

IV. Provider business mailing address

112 N MICHIGAN AVE APT 10
PASADENA CA
91106-1858
US

V. Phone/Fax

Practice location:
  • Phone: 626-440-7325
  • Fax:
Mailing address:
  • Phone: 818-404-7776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22702
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: