Provider Demographics
NPI:1245639699
Name:SHALOM, ELANA (PA)
Entity type:Individual
Prefix:
First Name:ELANA
Middle Name:
Last Name:SHALOM
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 1:7064 YELLOWSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3563
Mailing Address - Country:US
Mailing Address - Phone:718-355-9962
Mailing Address - Fax:
Practice Address - Street 1:7064 YELLOWSTONE BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3563
Practice Address - Country:US
Practice Address - Phone:718-355-9962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY017888Medicaid