Provider Demographics
NPI:1386052371
Name:CALLAHAM, NANCY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CALLAHAM
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 BAILEY ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2459
Mailing Address - Country:US
Mailing Address - Phone:818-397-1135
Mailing Address - Fax:
Practice Address - Street 1:212 BAILEY ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2459
Practice Address - Country:US
Practice Address - Phone:818-397-1135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9107943363AM0700X
CA55458363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical