Provider Demographics
NPI:1164877544
Name:SHESTAKOVA, GANNA (MD PHD)
Entity Type:Individual
Prefix:
First Name:GANNA
Middle Name:
Last Name:SHESTAKOVA
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:SHESTAKOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD PHD
Mailing Address - Street 1:15 N MEDICAL DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-1100
Mailing Address - Country:US
Mailing Address - Phone:801-583-2787
Mailing Address - Fax:
Practice Address - Street 1:15 N MEDICAL DR STE 1100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-1100
Practice Address - Country:US
Practice Address - Phone:801-583-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12256633-1205207ZP0007X, 207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology