Healthcare Provider Details

I. General information

NPI: 1023498276
Provider Name (Legal Business Name): SUPARNA N SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 S RAINBOW BLVD STE 250
LAS VEGAS NV
89118-1807
US

IV. Provider business mailing address

3016 W CHARLESTON BLVD STE 100
LAS VEGAS NV
89102-1973
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-6480
  • Fax: 702-671-6481
Mailing address:
  • Phone: 702-780-2315
  • Fax: 702-895-1014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD198475
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number23056
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: