Provider Demographics
NPI:1659776961
Name:SHADO, JONATHAN (STNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SHADO
Suffix:
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5866 ALBANY TRCE
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8890
Mailing Address - Country:US
Mailing Address - Phone:614-772-7012
Mailing Address - Fax:
Practice Address - Street 1:5866 ALBANY TRCE
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8890
Practice Address - Country:US
Practice Address - Phone:614-772-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401229350411376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3151664Medicaid