Provider Demographics
NPI:1306847207
Name:SHAH, HARENDRA P (PA-C)
Entity Type:Individual
Prefix:
First Name:HARENDRA
Middle Name:P
Last Name:SHAH
Suffix:
Gender:M
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 1:2744 W DEVON AVE
Mailing Address - Street 2:PRISM MEDICAL CENTER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1711
Mailing Address - Country:US
Mailing Address - Phone:773-262-1300
Mailing Address - Fax:773-262-1184
Practice Address - Street 1:2744 W DEVON AVE
Practice Address - Street 2:PRISM MEDICAL CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1711
Practice Address - Country:US
Practice Address - Phone:773-262-1300
Practice Address - Fax:773-262-1184
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001700363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical