Provider Demographics
NPI:1699318014
Name:FAKHRUTDINOV, DANYL L (PA-C)
Entity type:Individual
Prefix:
First Name:DANYL
Middle Name:L
Last Name:FAKHRUTDINOV
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 960
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5559
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:11333 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1116
Practice Address - Country:US
Practice Address - Phone:818-869-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant