Provider Demographics
NPI:1093439135
Name:CORUM, SHASTA R (BS)
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:R
Last Name:CORUM
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FOXCROFT AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-5341
Mailing Address - Country:US
Mailing Address - Phone:703-283-7002
Mailing Address - Fax:304-596-2392
Practice Address - Street 1:300 FOXCROFT AVE STE 307
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-5341
Practice Address - Country:US
Practice Address - Phone:703-283-7002
Practice Address - Fax:304-596-2392
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator