Provider Demographics
NPI:1417629221
Name:SHABANI, DIBA (PA-C)
Entity Type:Individual
Prefix:
First Name:DIBA
Middle Name:
Last Name:SHABANI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIBA
Other - Middle Name:
Other - Last Name:SAGHIZADEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2225 WILLIAMS TRACE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4440
Mailing Address - Country:US
Mailing Address - Phone:281-491-1911
Mailing Address - Fax:
Practice Address - Street 1:2225 WILLIAMS TRACE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4440
Practice Address - Country:US
Practice Address - Phone:281-491-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2021011607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant