Provider Demographics
NPI:1487209342
Name:SHAH, BISMA (PA-C)
Entity Type:Individual
Prefix:
First Name:BISMA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
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 1:20046 NW 66TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2139
Mailing Address - Country:US
Mailing Address - Phone:305-336-0447
Mailing Address - Fax:
Practice Address - Street 1:901 S STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-4522
Practice Address - Country:US
Practice Address - Phone:754-200-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1160980363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical