Healthcare Provider Details

I. General information

NPI: 1689087892
Provider Name (Legal Business Name): EHSAN EJAZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LA CASA VIA # 2-210
WALNUT CREEK CA
94598-3045
US

IV. Provider business mailing address

130 LA CASA VIA STE 210
WALNUT CREEK CA
94598-3035
US

V. Phone/Fax

Practice location:
  • Phone: 925-309-5155
  • Fax: 925-623-5156
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number56621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: