Healthcare Provider Details

I. General information

NPI: 1699487082
Provider Name (Legal Business Name): AFSOON ADL GOSTAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14550 HAYNES ST STE 204
VAN NUYS CA
91411-4112
US

IV. Provider business mailing address

6606 VARIEL AVE APT 501
CANOGA PARK CA
91303-3867
US

V. Phone/Fax

Practice location:
  • Phone: 818-672-9863
  • Fax:
Mailing address:
  • Phone: 424-537-6769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: