Provider Demographics
NPI:1194261073
Name:VESSALI, BEHRANG VAMEGHI (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:BEHRANG
Middle Name:VAMEGHI
Last Name:VESSALI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MR
Other - First Name:BEHRANG
Other - Middle Name:V
Other - Last Name:VESSALI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:12922 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2924
Mailing Address - Country:US
Mailing Address - Phone:818-760-2800
Mailing Address - Fax:818-760-9730
Practice Address - Street 1:12922 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2924
Practice Address - Country:US
Practice Address - Phone:818-760-2800
Practice Address - Fax:818-760-9730
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant