Provider Demographics
NPI:1679278410
Name:SHASTI-NAZEM, BEETA (DO)
Entity Type:Individual
Prefix:
First Name:BEETA
Middle Name:
Last Name:SHASTI-NAZEM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:BEETA
Other - Middle Name:
Other - Last Name:SHASTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:11919 SE 199TH CT
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-0564
Mailing Address - Country:US
Mailing Address - Phone:425-919-8595
Mailing Address - Fax:
Practice Address - Street 1:2211 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2742
Practice Address - Country:US
Practice Address - Phone:360-397-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program