Provider Demographics
NPI:1194425942
Name:SHAJAN PAUL, NIMMY
Entity type:Individual
Prefix:
First Name:NIMMY
Middle Name:
Last Name:SHAJAN PAUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 S FM 116 APT 10202
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-3653
Mailing Address - Country:US
Mailing Address - Phone:443-535-7824
Mailing Address - Fax:
Practice Address - Street 1:301 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-2653
Practice Address - Country:US
Practice Address - Phone:254-978-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40836122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist