Provider Demographics
NPI:1780494385
Name:BARKHORDAR, THEA RABI (PA)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:RABI
Last Name:BARKHORDAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 VENTURA BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5008
Mailing Address - Country:US
Mailing Address - Phone:818-751-9656
Mailing Address - Fax:
Practice Address - Street 1:17200 VENTURA BLVD STE 302
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5008
Practice Address - Country:US
Practice Address - Phone:818-905-8815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant