Provider Demographics
NPI:1538227681
Name:KHOURY, USAMA SALAMEH (PA-C)
Entity type:Individual
Prefix:MR
First Name:USAMA
Middle Name:SALAMEH
Last Name:KHOURY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:AUSAMA
Other - Middle Name:SALAMEH
Other - Last Name:AL-KHOURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 E VALENCIA ST
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-4334
Mailing Address - Country:US
Mailing Address - Phone:562-794-0553
Mailing Address - Fax:
Practice Address - Street 1:4055 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023
Practice Address - Country:US
Practice Address - Phone:323-780-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14511OtherPHYSICIAN ASSISTANT NO.