Healthcare Provider Details

I. General information

NPI: 1164664363
Provider Name (Legal Business Name): MANALI R SHAH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N ORLANDO AVE STE 200 BLDG D
WINTER PARK FL
32789-2988
US

IV. Provider business mailing address

PO BOX 102222 ATTN: CREDENTIALING DEPARTMENT
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 407-898-5452
  • Fax: 407-894-1183
Mailing address:
  • Phone: 239-274-8200
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105712
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: