Provider Demographics
NPI:1174777536
Name:SHISHIM, ELMIRA MIRA (PA)
Entity type:Individual
Prefix:
First Name:ELMIRA
Middle Name:MIRA
Last Name:SHISHIM
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WELLS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1377
Mailing Address - Country:US
Mailing Address - Phone:805-659-1740
Mailing Address - Fax:805-659-9959
Practice Address - Street 1:300 HILLMONT AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1651
Practice Address - Country:US
Practice Address - Phone:805-652-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19995363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical