Provider Demographics
NPI:1871819854
Name:SHANTA, MARK ALAN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:SHANTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 676
Mailing Address - Street 2:51 HIGH ST.
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464
Mailing Address - Country:US
Mailing Address - Phone:610-326-1250
Mailing Address - Fax:610-323-7812
Practice Address - Street 1:51 HIGH ST.
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464
Practice Address - Country:US
Practice Address - Phone:610-326-1250
Practice Address - Fax:610-323-7812
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF02340237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist