Basic Information
| Provider Information | |||||||||
| NPI: | 1083852370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | MALVERN-BRANDT | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22265 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032969200 | ||||||||
| FaxNumber: | 8032969297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2009 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | MA056652 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 0110002597 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 2550 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1083852370 | 01 | VA | MEDICARE | OTHER | 1083852370 | 05 | VA | MEDICAID | 2832PA | 05 | SC | MEDICAID |