Provider Demographics
NPI:1932640968
Name:SLAVKOVSKY, SHASTA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:MARIE
Last Name:SLAVKOVSKY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-4000
Mailing Address - Fax:208-302-4025
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:#503
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1338
Practice Address - Country:US
Practice Address - Phone:208-302-4000
Practice Address - Fax:208-302-4025
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55265363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner