Provider Demographics
NPI:1104112184
Name:SAMPAT, REENA SHAH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:REENA
Middle Name:SHAH
Last Name:SAMPAT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15785 LAGUNA CANYON RD STE 310
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3178
Mailing Address - Country:US
Mailing Address - Phone:949-453-4308
Mailing Address - Fax:
Practice Address - Street 1:15785 LAGUNA CANYON RD STE 310
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3178
Practice Address - Country:US
Practice Address - Phone:949-453-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant