Provider Demographics
NPI:1083164842
Name:SHAH, SHIVANI (PA-C)
Entity Type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:SHAH
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 1:6799 GREAT OAKS RD
Mailing Address - Street 2:100
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2588
Mailing Address - Country:US
Mailing Address - Phone:901-751-0405
Mailing Address - Fax:
Practice Address - Street 1:6799 GREAT OAKS RD
Practice Address - Street 2:100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38138-2588
Practice Address - Country:US
Practice Address - Phone:901-751-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant