=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992517916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAHAB NOURI PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2025
-----------------------------------------------------
Last Update Date | 01/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10532 CORAL KEY AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33647-3460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-920-5785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29549 N WAUKEGAN RD APT 101
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60044-5446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-920-5785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------