Provider Demographics
NPI:1861271603
Name:FALAHATIMARVAST, SHYLIE (PA-C)
Entity type:Individual
Prefix:
First Name:SHYLIE
Middle Name:
Last Name:FALAHATIMARVAST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHYLIE
Other - Middle Name:
Other - Last Name:FALAHATI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:34213 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2875
Mailing Address - Country:US
Mailing Address - Phone:949-248-4547
Mailing Address - Fax:
Practice Address - Street 1:34213 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2875
Practice Address - Country:US
Practice Address - Phone:949-248-4547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant