Healthcare Provider Details

I. General information

NPI: 1083164842
Provider Name (Legal Business Name): SHIVANI SHAH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6799 GREAT OAKS RD 100
MEMPHIS TN
38138-2588
US

IV. Provider business mailing address

6799 GREAT OAKS RD 100
MEMPHIS TN
38138-2588
US

V. Phone/Fax

Practice location:
  • Phone: 901-751-0405
  • Fax:
Mailing address:
  • Phone: 901-751-0405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3098
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: