Provider Demographics
NPI:1972024701
Name:DAVE, SHIVALI (PA-C)
Entity type:Individual
Prefix:
First Name:SHIVALI
Middle Name:
Last Name:DAVE
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 1:1824 E AZTEC LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 S PASEO DOROTEA STE 4A
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-1434
Practice Address - Country:US
Practice Address - Phone:951-297-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-01
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006167363A00000X
NV363A00000X
CAPA56713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant