Healthcare Provider Details

I. General information

NPI: 1073978573
Provider Name (Legal Business Name): KHUSHBU R SHAH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST STE 635E
LOS ANGELES CA
90048-5994
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-248-8245
  • Fax: 310-248-8249
Mailing address:
  • Phone: 310-248-8245
  • Fax: 310-248-8249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number66309
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4300
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4300
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: