Provider Demographics
NPI:1770581423
Name:MOINI, KATAYOUN (PA)
Entity type:Individual
Prefix:
First Name:KATAYOUN
Middle Name:
Last Name:MOINI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:MOINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:2040 E MARIPOSA AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5027
Mailing Address - Country:US
Mailing Address - Phone:213-266-5600
Mailing Address - Fax:562-548-2304
Practice Address - Street 1:2040 E MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5027
Practice Address - Country:US
Practice Address - Phone:213-266-5600
Practice Address - Fax:213-477-2344
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA813546133N00000X, 133V00000X
CAPA51495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA51495OtherCA LICENSE
AZZ126507Medicare PIN
RI007056590Medicare ID - Type Unspecified