Healthcare Provider Details

I. General information

NPI: 1033487145
Provider Name (Legal Business Name): SHUBHANGI B DESHMUKH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2011
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 MYRTLE AVE
EUREKA CA
95501-3425
US

IV. Provider business mailing address

2725 MYRTLE AVE
EUREKA CA
95501-3425
US

V. Phone/Fax

Practice location:
  • Phone: 800-453-3030
  • Fax: 800-328-3091
Mailing address:
  • Phone: 800-453-3030
  • Fax: 800-328-3091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006151
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60530735
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: