Provider Demographics
NPI:1992517916
Name:NOURI, SHAHAB (PA-C)
Entity type:Individual
Prefix:
First Name:SHAHAB
Middle Name:
Last Name:NOURI
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 1:29549 N WAUKEGAN RD APT 101
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-5446
Mailing Address - Country:US
Mailing Address - Phone:206-920-5785
Mailing Address - Fax:
Practice Address - Street 1:10532 CORAL KEY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3460
Practice Address - Country:US
Practice Address - Phone:206-920-5785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-25
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant