Provider Demographics
NPI:1588914493
Name:HAFIZI, MARJAN (PA-C)
Entity type:Individual
Prefix:
First Name:MARJAN
Middle Name:
Last Name:HAFIZI
Suffix:
Gender:F
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 1:4130 LA JOLLA VILLAGE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-625-7979
Mailing Address - Fax:858-625-2020
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9121
Practice Address - Country:US
Practice Address - Phone:858-625-7979
Practice Address - Fax:858-625-2020
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant