Provider Demographics
NPI:1700216322
Name:SHAH, RICKY J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:J
Last Name:SHAH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1771 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1242
Mailing Address - Country:US
Mailing Address - Phone:245-323-3872
Mailing Address - Fax:
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-876-8121
Practice Address - Fax:217-876-3077
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00586200363A00000X
IL085004825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant