Healthcare Provider Details

I. General information

NPI: 1659136745
Provider Name (Legal Business Name): CHIRAGKUMAR SHAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 TAVISTOCK RD
ST CATHARINES ON
L2M 6X7
CA

IV. Provider business mailing address

16 TAVISTOCK RD
ST CATHARINES ON
L2M 6X7
CA

V. Phone/Fax

Practice location:
  • Phone: 289-697-8339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number352536
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: