Healthcare Provider Details

I. General information

NPI: 1023871779
Provider Name (Legal Business Name): MGM PHYSICIAN ASSISTANT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 3RD ST STE 205
RIVERSIDE CA
92507-9000
US

IV. Provider business mailing address

1525 3RD ST STE 205
RIVERSIDE CA
92507-9000
US

V. Phone/Fax

Practice location:
  • Phone: 310-810-6554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: GINA HABEEB
Title or Position: CEO
Credential: PA
Phone: 951-788-2224