Provider Demographics
NPI:1003376898
Name:BAZARGAN-LARI, SHAWN-AMY RAE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:SHAWN-AMY
Middle Name:RAE
Last Name:BAZARGAN-LARI
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 FIDDLERS LN
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-5343
Mailing Address - Country:US
Mailing Address - Phone:518-785-8591
Mailing Address - Fax:
Practice Address - Street 1:475 WATERVLIET SHAKER RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4622
Practice Address - Country:US
Practice Address - Phone:518-785-1341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY511807163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03052893Medicaid