Basic Information
| Provider Information | |||||||||
| NPI: | 1548237662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOSEIN | ||||||||
| FirstName: | SHAH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 NW 13TH ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334862269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619556663 | ||||||||
| FaxNumber: | 5619552879 | ||||||||
| Practice Location | |||||||||
| Address1: | 2815 S SEACREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334357969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617377733 | ||||||||
| FaxNumber: | 5617335192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9104459 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 293004800 | 05 | FL | MEDICAID |