Provider Demographics
NPI:1619713229
Name:PRASAD, SHOMAL
Entity type:Individual
Prefix:
First Name:SHOMAL
Middle Name:
Last Name:PRASAD
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 1:2267 DEL MONTE DR
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1020
Mailing Address - Country:US
Mailing Address - Phone:510-565-9745
Mailing Address - Fax:
Practice Address - Street 1:2267 DEL MONTE DR
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-1020
Practice Address - Country:US
Practice Address - Phone:510-565-9745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant