Provider Demographics
NPI:1073267324
Name:SHAHSAVARI, PANTEA
Entity Type:Individual
Prefix:
First Name:PANTEA
Middle Name:
Last Name:SHAHSAVARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-1628
Mailing Address - Country:US
Mailing Address - Phone:540-532-8951
Mailing Address - Fax:
Practice Address - Street 1:118 BERKSHIRE DR
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-1628
Practice Address - Country:US
Practice Address - Phone:540-532-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV1821206228Medicaid
WV125553494Medicaid