Provider Demographics
NPI:1265880082
Name:CONNORS, PRUSHA PAKTINAT (PA-C)
Entity type:Individual
Prefix:
First Name:PRUSHA
Middle Name:PAKTINAT
Last Name:CONNORS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PRUSHA
Other - Middle Name:
Other - Last Name:PAKTINAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13044 MINDANAO WAY UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7635
Mailing Address - Country:US
Mailing Address - Phone:803-984-5091
Mailing Address - Fax:
Practice Address - Street 1:13365 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5134
Practice Address - Country:US
Practice Address - Phone:310-504-1829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant