Healthcare Provider Details

I. General information

NPI: 1497626188
Provider Name (Legal Business Name): SHIRA FELLUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEMPSTEAD TPKE
HEMPSTEAD NY
11549-0001
US

IV. Provider business mailing address

1000 HEMPSTEAD TPKE
HEMPSTEAD NY
11549-0001
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: --
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number035253-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: