Provider Demographics
NPI:1306407200
Name:PATEL, SHASTA (CRNP)
Entity Type:Individual
Prefix:MS
First Name:SHASTA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:MD
Mailing Address - Zip Code:21765-0434
Mailing Address - Country:US
Mailing Address - Phone:410-274-1401
Mailing Address - Fax:
Practice Address - Street 1:8900 COLUMBIA 100 PKWY STE G
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2336
Practice Address - Country:US
Practice Address - Phone:410-740-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR151007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily