Provider Demographics
NPI:1063923738
Name:KHOSHKERMAN, SHIRA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHIRA
Middle Name:
Last Name:KHOSHKERMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SHIRA
Other - Middle Name:
Other - Last Name:KHOSHKERMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
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:
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?:No
Enumeration Date:2017-10-20
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006666208M00000X
CAPA58912363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist