Provider Demographics
NPI:1164241923
Name:SHAH, KRUNAL UPENDRA
Entity type:Individual
Prefix:
First Name:KRUNAL
Middle Name:UPENDRA
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1781 S CAMPTON AVE UNIT 312
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6754
Mailing Address - Country:US
Mailing Address - Phone:858-603-5905
Mailing Address - Fax:
Practice Address - Street 1:1781 S CAMPTON AVE UNIT 312
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6754
Practice Address - Country:US
Practice Address - Phone:858-603-5905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030867363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty