Provider Demographics
NPI:1104179704
Name:HAIRSTON, SHAUNTE MONET (CPT)
Entity Type:Individual
Prefix:
First Name:SHAUNTE
Middle Name:MONET
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 COOKS LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1232
Mailing Address - Country:US
Mailing Address - Phone:410-365-5018
Mailing Address - Fax:
Practice Address - Street 1:1130 COOKS LN
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:410-365-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5000-609246RP1900X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No291U00000XLaboratoriesClinical Medical Laboratory