Healthcare Provider Details

I. General information

NPI: 1952196735
Provider Name (Legal Business Name): SHAH BANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DATES DRIVE, ITHACA NY 14850,CAYUGA MEDICAL CENTER
ITHACA NY
14850
US

IV. Provider business mailing address

101 DATES DRIVE, ITHACA NY 14850, INTERNAL MEDICINE RES
ITHACA NY
14850
US

V. Phone/Fax

Practice location:
  • Phone: 607-252-3457
  • Fax:
Mailing address:
  • Phone: 607-252-3457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: