Provider Demographics
NPI:1558922682
Name:VARGHESE, SHANI
Entity Type:Individual
Prefix:
First Name:SHANI
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANI
Other - Middle Name:VARGHESE
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 ST LUKES BLVD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-5670
Mailing Address - Country:US
Mailing Address - Phone:484-526-1000
Mailing Address - Fax:
Practice Address - Street 1:400 S GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-3776
Practice Address - Country:US
Practice Address - Phone:484-822-5205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT221775207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty