Provider Demographics
NPI:1679916027
Name:SHAH-GHASSEMZADEH, NICOLE KRISTINE (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:KRISTINE
Last Name:SHAH-GHASSEMZADEH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:KRISTINE
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:JERRY L. PETTIS MEMORIAL VETERANS HOSPITAL - GASTROENTE
Mailing Address - Street 2:11201 BENTON STREET
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92357
Mailing Address - Country:US
Mailing Address - Phone:909-558-4000
Mailing Address - Fax:
Practice Address - Street 1:JERRY L. PETTIS MEMORIAL VETERANS HOSPITAL - GASTROENTE
Practice Address - Street 2:11201 BENTON STREET
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA13979207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program