Provider Demographics
NPI:1972054377
Name:SHAMLOUL, IMAN
Entity type:Individual
Prefix:
First Name:IMAN
Middle Name:
Last Name:SHAMLOUL
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 1:1009 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ORELAND
Mailing Address - State:PA
Mailing Address - Zip Code:19075-2303
Mailing Address - Country:US
Mailing Address - Phone:302-668-9871
Mailing Address - Fax:
Practice Address - Street 1:140 NUTT RD
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3906
Practice Address - Country:US
Practice Address - Phone:610-983-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003896363A00000X
PAMA058540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant