Provider Demographics
NPI:1063852598
Name:POWERS, SHANTI SOPHIA (PA-C)
Entity type:Individual
Prefix:
First Name:SHANTI
Middle Name:SOPHIA
Last Name:POWERS
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 1:2168 GENERAL BOOTH BLVD STE 510
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-5804
Mailing Address - Country:US
Mailing Address - Phone:757-702-8122
Mailing Address - Fax:757-702-2184
Practice Address - Street 1:2168 GENERAL BOOTH BLVD STE 510
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5804
Practice Address - Country:US
Practice Address - Phone:757-702-8122
Practice Address - Fax:757-702-2184
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110004265OtherVA MEDICAL LICENSE