Provider Demographics
NPI:1538456090
Name:AGAHI, FALLON NASSIEM
Entity type:Individual
Prefix:MS
First Name:FALLON
Middle Name:NASSIEM
Last Name:AGAHI
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:FALLON
Other - Middle Name:NASSIEM
Other - Last Name:AGAHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:4080 CAVITT STALLMAN RD STE 100A
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9049
Mailing Address - Country:US
Mailing Address - Phone:916-771-0715
Mailing Address - Fax:
Practice Address - Street 1:4080 CAVITT STALLMAN RD STE 100A
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-9049
Practice Address - Country:US
Practice Address - Phone:916-771-0715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2025-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant