=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578359741
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENNA EBRAHIMI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2025
-----------------------------------------------------
Last Update Date | 09/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40910 FREMONT BLVD
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-4375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-276-2208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 MARIPOSA CIR UNIT 6
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94517-9801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------