Basic Information
| Provider Information | |||||||||
| NPI: | 1912306093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESAI | ||||||||
| FirstName: | SHRUTI | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9101 | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750199494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727457500 | ||||||||
| FaxNumber: | 9727454336 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MID CITIES BLVD | ||||||||
| Address2: | |||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760542430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174287300 | ||||||||
| FaxNumber: | 8174281085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2014 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA09232 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.