Provider Demographics
NPI:1881220234
Name:KASRAVI, SHIVA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:KASRAVI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHIVA
Other - Middle Name:
Other - Last Name:KASRAVI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2704 E ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-703-4496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58307363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program