Provider Demographics
NPI:1477078764
Name:SHAHA, NICOLE WARNER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:WARNER
Last Name:SHAHA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5155 E EAGLE DR UNIT 20730
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-3031
Mailing Address - Country:US
Mailing Address - Phone:480-706-9430
Mailing Address - Fax:480-378-2279
Practice Address - Street 1:4320 E PRESIDIO ST STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-1165
Practice Address - Country:US
Practice Address - Phone:480-706-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1477078764Medicaid