Healthcare Provider Details

I. General information

NPI: 1386314748
Provider Name (Legal Business Name): SHIVA E SEEJORE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PERRYRIDGE RD
GREENWICH CT
06830-4608
US

IV. Provider business mailing address

455 TARRYTOWN RD STE 1155
WHITE PLAINS NY
10607-1313
US

V. Phone/Fax

Practice location:
  • Phone: 203-863-3165
  • Fax:
Mailing address:
  • Phone: 917-834-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024027
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5419
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: