Healthcare Provider Details

I. General information

NPI: 1487365805
Provider Name (Legal Business Name): ANA JULIA KALSOOM AHMAD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 W 6TH ST
SAN PEDRO CA
90731-2521
US

IV. Provider business mailing address

593 W 6TH ST
SAN PEDRO CA
90731-2521
US

V. Phone/Fax

Practice location:
  • Phone: 310-547-0202
  • Fax:
Mailing address:
  • Phone: 310-547-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: