Provider Demographics
NPI:1801377627
Name:SHAH, PANKTI
Entity type:Individual
Prefix:
First Name:PANKTI
Middle Name:
Last Name:SHAH
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 1:1810 MARLANDWOOD RD APT 10204
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-2885
Mailing Address - Country:US
Mailing Address - Phone:909-672-4256
Mailing Address - Fax:
Practice Address - Street 1:ROSEWOOD RETIREMENT COMMUNITY
Practice Address - Street 2:5700 E. CENTRAL TEXAS EXPY
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543
Practice Address - Country:US
Practice Address - Phone:909-672-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300396225100000X
TX1279951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist