Provider Demographics
NPI:1679198857
Name:SHAH, SYED FAZAL (PMHNP)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:FAZAL
Last Name:SHAH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 HARRISON ST RM 126
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2305
Mailing Address - Country:US
Mailing Address - Phone:315-256-0055
Mailing Address - Fax:
Practice Address - Street 1:1967 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14221-8452
Practice Address - Country:US
Practice Address - Phone:415-278-7037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403108363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health