Provider Demographics
NPI:1770856080
Name:DWIVEDI, SHASHIKALA (PA)
Entity Type:Individual
Prefix:
First Name:SHASHIKALA
Middle Name:
Last Name:DWIVEDI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3774 SW 60TH TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-2530
Mailing Address - Country:US
Mailing Address - Phone:954-288-9839
Mailing Address - Fax:
Practice Address - Street 1:1401 CENTERVILLE RD
Practice Address - Street 2:SUITE300
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-558-1233
Practice Address - Fax:850-201-2544
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106431363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical