Provider Demographics
NPI:1124514773
Name:HAYKANI, BAHAREH (PA-C)
Entity type:Individual
Prefix:
First Name:BAHAREH
Middle Name:
Last Name:HAYKANI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 CANOGA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-2555
Mailing Address - Country:US
Mailing Address - Phone:310-882-1203
Mailing Address - Fax:
Practice Address - Street 1:18700 COLLINS ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1493
Practice Address - Country:US
Practice Address - Phone:310-882-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ7154363A00000X
CA58571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant