Provider Demographics
NPI:1528659984
Name:SHAH, SHEENA AMIN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:SHEENA
Middle Name:AMIN
Last Name:SHAH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9025 SYDNEY CT UNIT 12302
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1624
Mailing Address - Country:US
Mailing Address - Phone:909-456-6969
Mailing Address - Fax:
Practice Address - Street 1:502 EUCLID AVE STE 204
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2949
Practice Address - Country:US
Practice Address - Phone:619-331-3992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59071363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty