Healthcare Provider Details

I. General information

NPI: 1275072423
Provider Name (Legal Business Name): MANI KHALEGHI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5395 RUFFIN RD STE 204
SAN DIEGO CA
92123
US

IV. Provider business mailing address

PO BOX 98978
LAS VEGAS NV
89193-8978
US

V. Phone/Fax

Practice location:
  • Phone: 858-571-3630
  • Fax: 858-430-3146
Mailing address:
  • Phone: 702-216-3346
  • Fax: 702-671-6883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54238
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1823
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: