Provider Demographics
NPI:1104441328
Name:DIVEKAR, ISHANGI (PA-C)
Entity type:Individual
Prefix:
First Name:ISHANGI
Middle Name:
Last Name:DIVEKAR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ISHANGI
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2182 BRISTOL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7883
Mailing Address - Country:US
Mailing Address - Phone:773-814-8751
Mailing Address - Fax:
Practice Address - Street 1:4909 GREEN RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-3418
Practice Address - Country:US
Practice Address - Phone:919-790-0288
Practice Address - Fax:919-790-0723
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant