Provider Demographics
NPI:1487380275
Name:GHEYBI, TATIANA (PA-C)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:GHEYBI
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 1:10968 STALLION WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-6737
Mailing Address - Country:US
Mailing Address - Phone:909-816-9555
Mailing Address - Fax:
Practice Address - Street 1:999 N TUSTIN AVE STE 216
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6506
Practice Address - Country:US
Practice Address - Phone:714-545-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant