Provider Demographics
NPI:1710109392
Name:SHAH, SHABNAM DHIRENDRA (MSPA-C)
Entity Type:Individual
Prefix:MS
First Name:SHABNAM
Middle Name:DHIRENDRA
Last Name:SHAH
Suffix:
Gender:F
Credentials:MSPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:973-504-6326
Mailing Address - Fax:
Practice Address - Street 1:126 STATE ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5448
Practice Address - Country:US
Practice Address - Phone:973-504-6326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25MP00168300363A00000X
NJ25MP00168300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant