Basic Information
| Provider Information | |||||||||
| NPI: | 1386871614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | PALAK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2720 FAIRVIEW AVE N STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551131306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512415290 | ||||||||
| FaxNumber: | 6512415248 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 FAIRVIEW AVE N STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551131306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512415290 | ||||||||
| FaxNumber: | 6512415248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2009 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | 59805 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | 59805 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.