Healthcare Provider Details

I. General information

NPI: 1194395111
Provider Name (Legal Business Name): PUJA SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 W LINCOLN AVE
YAKIMA WA
98902-2437
US

IV. Provider business mailing address

2205 W LINCOLN AVE
YAKIMA WA
98902-2437
US

V. Phone/Fax

Practice location:
  • Phone: 509-469-6305
  • Fax:
Mailing address:
  • Phone: 509-469-6305
  • Fax: 509-575-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61480446
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: