Provider Demographics
NPI:1710621453
Name:BARUA, SHANAN (MD)
Entity Type:Individual
Prefix:
First Name:SHANAN
Middle Name:
Last Name:BARUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-2123
Mailing Address - Country:US
Mailing Address - Phone:516-305-2362
Mailing Address - Fax:
Practice Address - Street 1:222 STATION PLZ N
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3800
Practice Address - Country:US
Practice Address - Phone:516-663-8794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty