Healthcare Provider Details

I. General information

NPI: 1659876753
Provider Name (Legal Business Name): NOUR SHAHAB PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S FAIR OAKS AVE STE 305
PASADENA CA
91105-2562
US

IV. Provider business mailing address

541 W COLORADO ST STE 205
GLENDALE CA
91204-3640
US

V. Phone/Fax

Practice location:
  • Phone: 626-440-7325
  • Fax:
Mailing address:
  • Phone: 323-254-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA55438
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: