Provider Demographics
NPI:1871265041
Name:SHAH, NICOLE OMEHLA (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:OMEHLA
Last Name:SHAH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21308 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7912
Mailing Address - Country:US
Mailing Address - Phone:302-373-0927
Mailing Address - Fax:
Practice Address - Street 1:1945 NJ-33
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-897-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01203200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered