Healthcare Provider Details

I. General information

NPI: 1114419280
Provider Name (Legal Business Name): JANELLE A SHAH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N PARK PL STE 101
STOCKBRIDGE GA
30281-7237
US

IV. Provider business mailing address

135 N PARK PL STE 101
STOCKBRIDGE GA
30281-7237
US

V. Phone/Fax

Practice location:
  • Phone: 770-892-0300
  • Fax:
Mailing address:
  • Phone: 770-892-0300
  • Fax: 470-878-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60839895
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0007515
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: