Provider Demographics
NPI:1861800179
Name:KRISHNAMOORTHY, SHANKAR
Entity type:Individual
Prefix:
First Name:SHANKAR
Middle Name:
Last Name:KRISHNAMOORTHY
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 1:5456 QUEENSHIP CT
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-5969
Mailing Address - Country:US
Mailing Address - Phone:561-452-2431
Mailing Address - Fax:
Practice Address - Street 1:5456 QUEENSHIP CT
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-5969
Practice Address - Country:US
Practice Address - Phone:561-452-2431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9217170363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner