Healthcare Provider Details

I. General information

NPI: 1659639144
Provider Name (Legal Business Name): PUJA DIPAKKUMAR SHAH FNP, CMSRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 12/22/2023
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 E 17TH ST
SANTA ANA CA
92705-8505
US

IV. Provider business mailing address

1421 E 17TH ST
SANTA ANA CA
92705-8505
US

V. Phone/Fax

Practice location:
  • Phone: 714-922-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN 700630
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP 21691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: