Provider Demographics
NPI:1881349975
Name:SHAH, KRISHA (PA-C)
Entity type:Individual
Prefix:
First Name:KRISHA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 STONEBRIAR BLVD
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-8153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 E FLETCHER AVE STE 400
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4719
Practice Address - Country:US
Practice Address - Phone:813-580-5479
Practice Address - Fax:813-954-7530
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
FLPA9115729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant