Provider Demographics
NPI:1598336802
Name:SHUKLA, MANOJ KUMAR (APRN)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:KUMAR
Last Name:SHUKLA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 W TYVOLA RD # 2E27
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-7201
Mailing Address - Country:US
Mailing Address - Phone:704-329-1300
Mailing Address - Fax:
Practice Address - Street 1:3506 W TYVOLA RD # 2E27
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-7201
Practice Address - Country:US
Practice Address - Phone:704-329-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11009173363LA2200X
FLARNP11009173363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health