Provider Demographics
NPI:1154655744
Name:SHAH, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 UNION ST
Mailing Address - Street 2:WICKER WELLNESS CENTER
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-3103
Mailing Address - Country:US
Mailing Address - Phone:518-388-6794
Mailing Address - Fax:
Practice Address - Street 1:807 UNION ST
Practice Address - Street 2:WICKER WELLNESS CENTER
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-3103
Practice Address - Country:US
Practice Address - Phone:518-388-6794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430450-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care