Provider Demographics
NPI:1912400318
Name:PRASAD-CLERVE, SHAMI LATA
Entity Type:Individual
Prefix:
First Name:SHAMI
Middle Name:LATA
Last Name:PRASAD-CLERVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4311
Mailing Address - Country:US
Mailing Address - Phone:510-374-8741
Mailing Address - Fax:
Practice Address - Street 1:600 NUT TREE RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4669
Practice Address - Country:US
Practice Address - Phone:707-359-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA758298163W00000X
CA95005239207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine