Provider Demographics
NPI:1588735849
Name:IBRAHIMI, ISAAC A (PA-C)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:A
Last Name:IBRAHIMI
Suffix:
Gender:M
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:PO BOX 11101
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1101
Mailing Address - Country:US
Mailing Address - Phone:866-878-5075
Mailing Address - Fax:
Practice Address - Street 1:19850 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4002
Practice Address - Country:US
Practice Address - Phone:510-582-8555
Practice Address - Fax:510-581-8686
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18248OtherLICENSE
CAPA18248Medicaid
CAPA18248Medicare UPIN
CAPA18248OtherLICENSE