=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699446138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRISCILLA NICOLETTE NIKOGHOSSIAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2021
-----------------------------------------------------
Last Update Date | 09/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 E CESAR E CHAVEZ AVE STE 2500
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-268-6731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9245 SCOTMONT DR
-----------------------------------------------------
City | TUJUNGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91042-3336
-----------------------------------------------------
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 |
-----------------------------------------------------