Provider Demographics
NPI:1346951316
Name:SHAH, NISHA J (PA-C, DMSC)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:J
Last Name:SHAH
Suffix:
Gender:F
Credentials:PA-C, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 CAREY DR
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-4908
Mailing Address - Country:US
Mailing Address - Phone:630-770-2888
Mailing Address - Fax:
Practice Address - Street 1:911 N ELM ST STE 128
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3640
Practice Address - Country:US
Practice Address - Phone:630-856-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.0090762085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology