Provider Demographics
NPI:1164664363
Name:SHAH, MANALI R (PA)
Entity Type:Individual
Prefix:
First Name:MANALI
Middle Name:R
Last Name:SHAH
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:460 N ORLANDO AVE
Practice Address - Street 2:STE 200 BLDG D
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2988
Practice Address - Country:US
Practice Address - Phone:407-898-5452
Practice Address - Fax:407-894-1183
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2022-09-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9105712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111000300Medicaid