Provider Demographics
NPI:1194381020
Name:THARAKAN, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:THARAKAN
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 1:127 THE DELL
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1014
Mailing Address - Country:US
Mailing Address - Phone:516-270-2721
Mailing Address - Fax:
Practice Address - Street 1:11912 94TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1332
Practice Address - Country:US
Practice Address - Phone:718-297-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344111363LF0000X
NYF344111-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily