Provider Demographics
NPI:1053614115
Name:REMTULLA, SHAMIM MOHAMED (PA-C)
Entity type:Individual
Prefix:
First Name:SHAMIM
Middle Name:MOHAMED
Last Name:REMTULLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHAMIM
Other - Middle Name:
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3736 MCLAUGHLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8900 VENICE BLVD STE 109
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2361
Practice Address - Country:US
Practice Address - Phone:424-282-5696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21180363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical