Basic Information
| Provider Information | |||||||||
| NPI: | 1679827117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALI | ||||||||
| FirstName: | AMI | ||||||||
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| Credential: | PA | ||||||||
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| OtherLastName: | SHAH | ||||||||
| OtherFirstName: | AMI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585547439 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10862 CALLE VERDE | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919417340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585547439 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2012 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA51686 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.