Provider Demographics
NPI:1689709917
Name:SHASTEEN, TAMARA (NP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:SHASTEEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3755 E MAIN ST STE 190
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2463
Mailing Address - Country:US
Mailing Address - Phone:630-549-6245
Mailing Address - Fax:630-701-9500
Practice Address - Street 1:3755 E MAIN ST STE 190
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2463
Practice Address - Country:US
Practice Address - Phone:630-549-6245
Practice Address - Fax:630-701-9500
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14669363LP0200X
IL209007817363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN619027Medicaid
CAQ48895Medicare UPIN
CAZZZ02174ZMedicare ID - Type Unspecified