Healthcare Provider Details

I. General information

NPI: 1346613676
Provider Name (Legal Business Name): SHIVALI P MANIAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PLATINUM PT
LAKE MARY FL
32746-4871
US

IV. Provider business mailing address

701 PLATINUM PT
LAKE MARY FL
32746-4871
US

V. Phone/Fax

Practice location:
  • Phone: 407-206-4500
  • Fax: 407-643-2802
Mailing address:
  • Phone: 407-206-4500
  • Fax: 407-643-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9108970
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9108970
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: