Provider Demographics
NPI:1427421569
Name:FOROUZAN, BAHARAK (PA)
Entity type:Individual
Prefix:
First Name:BAHARAK
Middle Name:
Last Name:FOROUZAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BAHARAK
Other - Middle Name:
Other - Last Name:FOROUZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17730 VALLE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-1002
Mailing Address - Country:US
Mailing Address - Phone:858-373-7126
Mailing Address - Fax:
Practice Address - Street 1:15611 POMERADO RD STE 525
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2439
Practice Address - Country:US
Practice Address - Phone:858-485-5301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical