MEDICARE: GHAZAL POOYA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA21397	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA21397	OTHER	CA	PA LICENSE

General Provider Information

NPI Number	:	1629352588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GHAZAL POOYA

Provider Business Mailing Address
First Line	:	20969 VENTURA BLVD STE 24
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-6622
Country	:	US
Telephone Number	:	310-425-4810
Fax Number	:

Provider Business Practice Location Address
First Line	:	20969 VENTURA BLVD STE 24
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-6622
Country	:	US
Telephone Number	:	310-425-4810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2011
Last Update Date	:	08/25/2014

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Directions to “ GHAZAL POOYA ” Practice Location

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