Provider Demographics
NPI:1306337753
Name:PERSAD, SHIVANAND VIJAY (PA-C)
Entity type:Individual
Prefix:
First Name:SHIVANAND
Middle Name:VIJAY
Last Name:PERSAD
Suffix:
Gender:M
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 1:7050 W PALMETTO PARK RD STE 30
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3463
Mailing Address - Country:US
Mailing Address - Phone:954-425-9154
Mailing Address - Fax:866-981-1882
Practice Address - Street 1:7050 W PALMETTO PARK RD STE 30
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3463
Practice Address - Country:US
Practice Address - Phone:954-425-9154
Practice Address - Fax:866-981-1882
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135224207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty