Provider Demographics
NPI:1366939589
Name:SHAHABUDDIN, AMENA (PA-C)
Entity type:Individual
Prefix:
First Name:AMENA
Middle Name:
Last Name:SHAHABUDDIN
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 1:726 CIMARRON TRL
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4405
Mailing Address - Country:US
Mailing Address - Phone:972-839-7244
Mailing Address - Fax:
Practice Address - Street 1:4815 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2705
Practice Address - Country:US
Practice Address - Phone:915-215-4600
Practice Address - Fax:915-545-7338
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11950363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant