Provider Demographics
NPI:1134092851
Name:FAISAL, SHAH
Entity type:Individual
Prefix:
First Name:SHAH
Middle Name:
Last Name:FAISAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 ALMDALE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8427
Mailing Address - Country:US
Mailing Address - Phone:260-804-0792
Mailing Address - Fax:
Practice Address - Street 1:1005 ALMDALE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-8427
Practice Address - Country:US
Practice Address - Phone:260-804-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28274111A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty