Provider Demographics
NPI:1730125295
Name:STUPART, SHAUNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAUNA
Middle Name:
Last Name:STUPART
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:PO BOX 1439
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20830-1439
Mailing Address - Country:US
Mailing Address - Phone:202-483-8196
Mailing Address - Fax:
Practice Address - Street 1:9501 FARRELL ROAD
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060
Practice Address - Country:US
Practice Address - Phone:703-805-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81014207Q00000X
VA0101239167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I03833Medicare UPIN