Provider Demographics
NPI:1336304427
Name:MASK, SHANTALA (PA)
Entity Type:Individual
Prefix:
First Name:SHANTALA
Middle Name:
Last Name:MASK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 N 75TH AVE
Mailing Address - Street 2:STE. 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-3171
Mailing Address - Country:US
Mailing Address - Phone:623-849-2220
Mailing Address - Fax:623-849-2574
Practice Address - Street 1:4136 N 75TH AVE
Practice Address - Street 2:STE. 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-3171
Practice Address - Country:US
Practice Address - Phone:623-849-2220
Practice Address - Fax:623-849-2574
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2911363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2911OtherPHYSICIAN ASSISTANT LICENSE