Provider Demographics
NPI:1477078764
Name:SHAHA, NICOLE WARNER (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:WARNER
Last Name:SHAHA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2545 E INTREPID AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-7028
Mailing Address - Country:US
Mailing Address - Phone:208-716-2350
Mailing Address - Fax:480-378-2279
Practice Address - Street 1:2545 E INTREPID AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7028
Practice Address - Country:US
Practice Address - Phone:208-716-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6826363AS0400X
363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1477078764Medicaid